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A RECORD 



OF THE 



VBOICAL CLIIIC 



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HELD AT THE 



jj. 2- JOMCEOPATHIC JlEDICAL foLLEGE 



DM^rftS THE St§8t@NI OF I8?4-'?S. 



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PHILETUS eh STEPHENS, 



TO WHICH IS ADDED A SYNOPSIS OP THE CLINICS OF 18T3-'74. 



1875. 





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Entered according to Act of Congress, in the year 187P, 

By PHILETUS J. STEPHENS, 

In the office of the Librarian of Congress at Washington. 



To 

or TEE 

New Yoi 4 k J|on]oeo^ktl\ic Medidal dolle^ 

THIS WORK 

IS RESPECTFULLY SUBMITTED, 

BY 

PHILETUS J. STEPHENS. 



PREFACE 



Duking the last session of the New York Homoeopathic Medical 
College the undersigned was often struck with the brilliancy of the 
Surgical Clinics, and then determined, if he were spared another 
term, he would publish these Clinics, not onl}^ for the advancement 
of the college in which they were delivered, but for the good of the 
Homoeopathic cause generally. The method of conducting the 
lecture is as follows : the patients are sent from the Dispensary to 
the Amphitheatre and are introduced one by one to the class. 

There is not any selection of cases, or opportunity afforded for 
the lecturer to examine the patient, make up his diagnosis, select 
his remedy and prepare what apparatus is best; and for these 
reasons the author has endeavored to give the record in full, that 
the Clinics may appear, not dressed up with rhetoric and illustration, 
but as they really took place. The author also desires, at the request 
of Prof. Helmuth, to state that he (Prof. Helmuth) was unaware 
that these Clinics were being reported verbatim as they fell from 
his lips, until the session was almost over, and then he was for the 
first time made aware of the fact by the printed proof sheets being 
presented for his inspection. 

The author conceived that by keeping the matter entirely private 
during the term that he could more certainly offer to the students, 
the faculty of the college and the public the method in which 
Clinical Surgery is taught in the New York Homoeopathic College, 
which, he conceives, has no superior in this country. 

PHILETUS J. STEPHENS. 



SURGICAL CLINICS OF 1874-75 

OF THE 

3j{w lht\ Ijontttojiatfjit Jjfylttal fyo%$. 



The Session of the New York Homoeopathic Medical College 
for 1874 and 75 commenced October 10th, 1874, in the large and 
elegant Amphitheatre, under most favorable auspices. 

At the first Clinic there were present more than one hundred 
students, and more patients applied than could be attended to ; 
indeed, throughout the entire session, this has been the case. 

These Clinics are always lively, pleasant and attractive to 
students as well as physicians, and give entire satisfaction; they 
sparkle with humor, and reflect great credit upon Professor "Win. 
Tod Helmuth, who, Ave think, proves himself a perfect master of 
the art of surgery. The chief peculiarity of the Clinics are the pro- 
miscuous and rapidly given " quizzes." 



£w0fcul CUnw of ftjctotuv 10. 

A boy being brought in with his arm in a splint, Professor Wm. 
Tod Helmuth looked at it for a moment, and commenced to ques- 
tion the class as follows : 

What do we understand by the term fracture ? Answer. — A 
solution of continuity of the Osseous System ; or, in other words, 
a separation or breakage of the bones, by various causes, both di- 
rect and indirect. A fracture ma}' be known by pain, loss of 
power, and crepitus, or peculiar sensation from rubbing the ends 
of the broken bones together. 

What various divisions of fractures are recognized by surgeons ? 
Simple, Compound, Comminuted, Impacted, Complete, and Incom- 
plete Fracture. 

What is a simple fracture ? Is when the bone is broken at one 
point, without any wound of the flesh. 



8 FRACTURE QUIZZES. 

What is a compound fracture ? Is one where there is a break- 
age of the bone, with a wound of the soft parts. 

"What is a comminuted fracture ? Is one where the bone lias 
been broken in more than one place, or cracked in many places. 

What is a compound comminuted fracture? One where the 
bone is splintered, or the breakage of bones into several fragments 
with, accompanying wounds of the soft parts. 

What is an impacted fracture ? One in which one extremity 
or portion of the bone is wedged or driven into the other. 

What is a complete fracture ? One in which there is an entire 
separation of the bone. 

What is an incomplete fracture ? One in which there is but a 
partial division of the osseous material. 

What terms are used to designate the directions in which the 
separation may occur ? Transverse, longitudinal, oblique or 
serrated fracture. 

What is a transverse fracture ? One which is directly across 
the bone. 

What is a longitudinal fracture ? One which runs lengthwise 
of the bone. 

What is an oblique fracture ? One in which the line of fracture 
runs from side to side in an oblique direction, or obliquely to the 
base of the bone. 

What is reduction? Petting a fracture: that is, bringing 
the ends of the broken bones together and adjusting them to 
each other in their natural position, embracing extension, 
counter extension, and coaptation. 

What is extension ? The taking hold of the limb below the 
fracture and making traction from the body* 

What is counter extension? Traction above the fracture 
towards the body, or steadying the body. 

Must this opposite traction be done at the same time ? Yes ; 
to overcome the force of the muscles, which contract and draw 
the ends of the broken bone over each other and so shorten 
the limb. 

Sometimes extension and counter extension are not required. 
What is coaptation? Adjusting the ends of the bones to each 
other. 

What would you do with a fractured limb ? Would set the 
bones : that is, restore the fragments as nearly as possible to 



CASE OF FRACTURE OF THE HUMERUS, ETC. 9 

their natural position, keeping the ends of the broken bone in 
contact by mechanical contrivances, such, as bandages, pads, 
splints and rollers, so as to maintain them in such position that 
nature may have a fair chance to unite the broken bone together. 
What next would you do ? Prevent or allay constitutional or 
local disturbances. 



;frr*«tttr* <of tire &Mt«rti** 



John A. Powers, Aged Five Years. 

The first case to-day is one of fracture. By fracture, I 
mean a breakage of the bone, or ossiflc matter — a solution of 
continuity in any of the bony structures of the human body. 

It is always of great importance when looking at a fracture and 
making your diagnosis to find out, if you can, the position of the 
patient at the time that the injury was received. In a patient so 
young as this we will be unable to discover how he fell, whether 
on his arm or not. 

The next thing to be done when a patient is brought to you 
with a fracture is to look for the three signs thereof, which are 
almost always present. These three symptoms are crepitus, preter- 
natural mobility and deformity. There are other symptoms, but 
these are the three generally found, and these demand attention. 

It is always important in a case of fracture to try to ascertain, if 
we can, if crepitus be present — and by the term crepitus we under- 
stand the sound which is produced and emitted when the fractured 
extremities of a bone are rubbed together, or the grating together 
of the two ends of a fractured bone, and the peculiar sensation 
that is felt by a surgeon during a careful examination. 

True crepitus, in itself, is always diagnostic of a fracture. When 
I say crepitus, I mean true crepitus. You must be careful not to 
mistake true for false crepitus, which you often find in that pecu- 
liar rubbing noise that may be distinctly heard in the irritated 
sheaths of tendons and joints, or from accumulation of air in the tis- 
sues. True crepitus is not only felt, but often heard. It resembles, as 
closely as possible, to the ear the sound produced by the rubbing 
together of two pieces of loaf sugar. If you have a patient brought 



10 FRACTURE, PRETERNATURAL MOBILITY, ETC. 

to you with supposed fracture, and you can find true crepitus, you 
do not want anything else. 

You must also bear in mind an important fact, that a fracture 
may exist without crepitus. Thus, in the so-called impacted frac- 
tures, or in those where strong muscular contraction draw asunder 
the fragments, there may not be a trace of the sound, and I would 
have this point strongly impressed upon the mind. 

Preternatural Mobility. — This symptom is generally pres- 
ent in fractures, although, in the bones of the leg and forearm, 
when one bone only is the seat of injury, the increased motion 
may be very slight, as may also be noticed in the impacted 
variety; but by grasping the fractured bone above the contusion 
and holding it firmly and moving the lower portion of the bone in a 
lateral direction, an unnatural motion may be generally observed. 

This preternatural mobility may also be difficult to recognize — 
especially when the bony lesion takes place in the vicinity of a 
joint and there is much contusion of the soft parts which may be 
torn or lacerated. 

Preternatural mobility is more frequently found in the shafts of 
bones than in fractures in the vicinity of the joints, because when 
you have a fracture in the vicinity of the joint there is generally 
so much swelling that there is less mobility than usual. But 
if you have a fracture in the shaft of the humerus, or if you have 
both bones of the forearm broken, then, of course, there will be 
mobility, when, under ordinary circumstances, there would be 
none. 

We have not time now to enter into a discussion of fractures 
and the different methods of treatment. It is very interesting, but 
would occupy too much time. 

It is always well when you have to treat a fracture to act with 
the utmost delicacy, otherwise you are very apt to bruise the tissues. 

Here is a fracture which is somewhere in the vicinity of the 
elbow joint — and fractures in the vicinity of the elbow joint are 
sometimes the most difficult that you have to deal with. I think 
that Gross says in his work that he never approaches a surgical 
case with as much fear and misgiving as he does fractures in the 
vicinity of the elbow, no matter how slight, because in eight cases 
out of ten they are liable to be followed with a certain amount of 
deformity. More or less stiffness in the joint is a result which, 
even under the most careful treatment, cannot be prevented. 



CASE OF FRACTURE OF THE HUMERUS, ETC. 11 

We must find out exactly where this fracture is. In the first 
place I support the hand and turn it in this way (supinating). 
Now, I know very well that the neck of the radius is not broken, 
because if it was the head of the bone would not move between 
my fingers. If the head of the radius were broken off I could not 
move it in the way that I am now doing. 

The next thing we do is to lift the hand up in this way (illus- 
trating). Then I feel for the olecranon process on the other side 
of the elbow, and I find that it is intact. 

This boy has a fracture of the external condyle. 

When you come to diagnose fractures about the elbow be 
extremely careful about your prognosis. There are frequently 
suits for malpractice on account of fractures about the elbow. 
There has been a recent case at Paterson, concerning which I have 
been consulted. Therefore I say that in the treatment of fractures 
about the joints you must always be exceedingly careful how you 
give an opinion. 

I will remark in respect to this patient that he will have a pretty 
quick recovery, but that he may have stiffness in the joint. The 
reason for that stiffness I will explain to you hereafter, when we 
come to understand the process of repair, and the inflammatory 
action which results from an injury of this character. Inflam- 
matory action may extend itself into the cavity of the joint, and 
a certain amount of plastic matter be effused, which will result in 
spurious anchylosis. 

In a case like this the best dressing is a posterior rectangular 
splint. You can make it out of a segar box. 

The chances for the recovery of this child are better than they 
would be if he were older. There will not be so much likelihood 
of trouble at the joint. 

It is a question with a great many surgeons as to whether a 
bandage should be applied next to the skin before putting on a 
splint. Of course, there are many who say that a bandage should 
be so applied, and give as a reason that, while it controls mus- 
cular action, it also affords an equable and even support to the part. 
That is all very true in its way. On the other hand, those who 
are in favor of the non-application of a bandage next to the 
skin give it as their opinion that it certainly arrests the cir- 
culation. Xo matter how lightly the bandage is put on, the cir- 
culation may be arrested ; therefore, it is a matter which is open 



12 CASE OF FRACTURE OF THE HUMERUS, ETC. 

to the judgment of every discriminating surgeon whether or 
not he shall apply a bandage before he applies the splint. 
In a case like this I would suppose it better not to put a bandage 
next to the skin at all ; but if we have adhesive plaster handy we 
will secure the arm in proper position simply by the use of the 
posterior rectangular splint with adhesive straps. 

It is hardly my province now to enter into the anatomy of the 
lower end of the humerus, although it is very important to 
know what muscles (flexors and extensors) there are, and how 
they are attached ; but we will defer this until some other time. 

It is important for you to recollect that the deposit of osseous 
matter does not take place in a fracture until the seventh or eighth 
day ; and, therefore, you are to apply your splints and keep the 
parts in good position for seven or eight days, and then it is well 
to examine the fracture again. If the parts are in position 
apply a permanent bandage. But if you come to your patient 
the day after the first dressing and find that there is a tendency to 
swelling, and that the nails begin to look blue, take the bandage 
off. or else nick it ; there are more arms and legs lost by surgeons 
through tight bandaging than from bad treatment of the fractures. 
If you could examine into the literature of surgery you would 
see that in a great many cases the loss of a limb has been occa- 
sioned by tight bandaging. It seems to have been a notion of the 
surgeons in the olden time that when they applied a bandage they 
must use a good deal of force, to wrap it tightly around, in order 
to keep the bone in position. This is a wrong principle from be- 
ginning to end — a moderately tight bandage, such as you see here, 
is all that is necessary. 

We will first pack this splint well with cotton. 

Doctors make more mistakes, ten to one, than surgeons. You 
may put that down as a rule. The difference is just this: the 
doctors bury their errors under the sod, while a surgeon's mis- 
takes are held up to posterity. 

This boy will probably come back to us this day week. We 
will then have his arm undressed and look at it, to see how it does. 
The bandage is now put on quite loosely, but it will keep his 
arm in that position. Even now there may be some little tend- 
ency to swelling of the fingers. It is always better to watch 
such fractures closely. 

In the case over in Paterson, in which I was called to testify 



CASE OF LARGE N^EVUS, ETC. 13 

the other clay, the band?ge had been applied quite tightly, 
gangrene had resulted and the arm been amputated. That was 
three years ago. They buried the arm in the earth. One man 
swore that the olecranon process was broken off. Another phy- 
sician said that the head of the radius was severed. Another 
that the coronoid process of the ulna was fractured, and 
others that the internal condyle of the humerus was separated. 
They said that they had the bones to prove it. "There was 
no getting around the bones;' 1 so they dug up the arm a year 
and a half after it was buried, but all these parts had separated, 
because the epiphyses had not united with the shaft, and the long 
burial had consequently separated these parts. There were 
so many conflicting opinions about it that it seems rather 
doubtful whether the bone was broken at all. 

In the treatment of fractures we employ two forces in set- 
ting the bone; one of these forces is called "extension," 
the other counter extension. Extension is always made in a 
direction from the body, and the counter extension is always 
made in a direction towards the body. In order to reduce a 
fracture a considerable amount of extension and counter exten- 
sion may be employed. The object of this is to overcome the 
action of certain muscles which, being inserted below the seat of 
fracture, have a tendency to make the bones "ride" one on the 
other. 

Prof. Gross speaks of fractures as follows : " If I were called 
upon to testify under oath what branch I regard as the most try- 
ing and the most difficult to practice successfully and creditably, 
I would unhesitatingly assert fractures." 

This indicates the importance of thoroughly understanding 
the subject. 



Ida Teller, Aged Five Months. 

This case is one that came from the Surgical Hospital under 
the charge of Dr. Thompson. 

It is known as naevus, which is an enlargement of the capillary 



14 CASE OF NtEVUS TKEATMENT, ETC 



vessels ; naevi are flat, slightly elevated, and of a red or purplish, 
hue ; they are usually small, and occur most frequently on the head, 
face, neck and arms. The contained blood may be arterial or 
venous, or a mixture of the two. 

As a general rule their growth does not attain a size much 
larger than an egg. 

The appearance is sometimes called " mother's mark." A true 
aneurism is different from a naevus. A naevus is an enlargement 
of the capillaries of the arteries and veins, whereas a true aneurism 
by anastomosis is nothing more nor less than an enlargement of 
the arterial capillaries rather than of the veins. 

Naevi are sometimes very difficult to treat. They are generally 
found at birth. In fact I have never yet heard of one which, was 
not present at birth. They vary in size, from that of the head of 
a large pin to several inches in diameter. They are caused by an 
enlargement of the smaller blood vessels of the part, and by an in- 
creased action of the heart and vessels tending to throw the blood 
to that part The capillaries are enlarged, and, not having the 
power of passing the blood through them, the parts become 
enlarged and reddened. These naevi are always worse when the 
child cries, because then an additional amount of blood is thrown 
into the tissues. 

There are a variety of methods employed for the relief of these 
nsevi. A simple naevus may be removed, when it consists of a 
red spot, by vaccination, or by application of collodion with 
pressure. When situated over a bone the tumor may be treated 
by compression with pads of ivory or other hard substances. Or 
you take a needle and thread it with an ordinary piece of silk, dip 
the silk in dilute nitric acid, run the needle beneath the naevus 
and let the ends of the ligature hang. Injections of persulphate 
or perchloride of iron, sulphate of zinc, acetate of iron, matico, 
tannin and ether astringents may prove useful. 

Dr. Gross speaks highly of the topical application of Vienna 
paste. Dr. Valentine Mott advised puncture with red hot needles, 
or acupressure pins. Perhaps the best method of treating naevi is 
by electrolysis or galvano puncture. Many successful cures are 
on record. Some surgeons prefer nitrate of silver or the actual 
cautery. Or you may apply collodion over the surface. This has 
a tendency, from its contractile powers, to force out the blood, 
and it is a very excellent dressing after an operation for 



TREATMENT OF NiEYTJri, ETC. 15 

naevus lias been performed. Another method is the introduction 
of pins deep down under the tumor, and strangling the growth 
by ligature underneath the pins. There is another method — by 
passing a double thread under the base of the tumor, leaving the 
strands hanging out in opposite directions, then passing the 
needle through at right angles, cutting the strands, and 
tying those above and those below. Another practice is to ligate 
the main vessel giving the supply of blood. I have myself em- 
ployed this treatment for a naevus occupying half the side of a 
child's head. The growth had attained the size of half an ordi- 
nary sized melon, for which I ligated the common carotid below 
the omo-hyoid after failure by other means. At first the tumor 
diminished one half, then remained stationary for a time, and has 
since disappeared. But one of the best methods known } r ou will 
see employed to-day. This child has been operated on twice 
with a red hot iron, the marks of which you can see. 

This naevus is a large one, and is in a very peculiar position — 
on the nose. It is not in a position where the parts are all smooth, 
and you have a plain surface to work upon, but it is so situated 
as to require a great deal of care in the operation, and the process 
itself is by no means devoid of danger. 

The operation which Dr. Thompson proposes to perform is this : 
He has prepared a round needle — and the reason that a round one 
is used is because these broad, cutting needles often give rise to 
a great deal of hemorrhage; the needle is very sharp, and it is 
threaded with a long piece of silk thread (made of new braided 
silk, which will not kink or break), about six feet in length, one 
half of which is black and the other white. Thread the 
needle upon the middle of this cord. I will give you the history 
of the operation, and then you will see it clone. You enter the 
needle at about one quarter of an inch from the end of the tumor, 
and pass the needle several times beneath the naevus. The loops 
should be three quarters of an inch apart and the last one be 
brought out through the healthy tissue, beyond the tumor. Thus 
we have double loops — one white and one black — on each side. 
Cut the white loops on one side and the black on the other, or at 
the top you keep all the thread of one color and at the bottom you 
keep all the thread of the other color. Then tie firmly the white 
threads on one side and the black on the other side, and the naevus 
is effectually strangulated. 



16 CASE OF NiEVUS, ANESTHESIA, ETC. 

The prognosis in the case cannot be said to be remarkably 
favorable, but nevertheless we will have to do the best we can. But 
it is certain that unless an operation is performed there can be no 
help for the child. A profuse hemorrhage would soon result. 
This is the only means left to save the life of this child. It is a 
perfectly well understood matter between the parents and the 
operator that they assume all the responsibility in this case. The 
father has been told all about it. He knows that it is a dangerous 
operation, but he wishes it performed because he knows that it is 
the only thing that can be done, and he is willing to assume all 
the responsibility ; he is anxious to have the child live ; there is 
no doubt of that. It is in just such cases that surgery steps in. 
The question arises — Is there anything in medicine that will do 
this child good? Will all the medicine of all the schools be able 
to cure this naevus? 1 do not think there is a chance for it in 
medicine. "When the physicians get into trouble they often 
come to the surgeon, and when the surgeon fails there is no 
power on earth to*-save. 

This naevus has been extending daily. In this operation wo 
shall use an anaesthetic. You all know, gentlemen, that anaes- 
thesia is the next step to death. It simulates death. It takes but 
a very little more of the anaesthetic agent to step from a previous 
life into death. Therefore, it behooves us when we would ad- 
minister such an agent to select that one which is the best. 
When I say the " best," I mean that agent which is safest, and not 
that which is the quickest, unless the quickest is the safest. Of 
course, you know that the discovery of ether belongs to America. 
The discovery of chloroform, or, more properly speaking, the in- 
troduction of chloroform, belongs to England. Weils and Morton 
claim priority of discovery in this country, while Simpson lays 
claim to it in England. 

The American Medical Association, at its meeting held at 
Washington in' 1870, passed the following resolution: "Dr. 
Horace Wells, of Hartford, Conn., was the discoverer of anaesthe- 
sia." Very distinguished gentlemen, while giving the discovery 
of nitrous oxide anaesthesia to Dr. Wells, accord priority of the sul- 
phuric ether anaesthesia to Dr. Wm. T. G. Morton, of Boston. 
Not many years since one of the greatest surgeons, Velpeau, of 
Paris, told his medical pupils that although enthusiasts at different 
times had vainly imagined that some means might be adopted to 



ANAESTHESIA. 17 

allay the pain of surgical operations, yet that such an idea was en- 
tirety chimerical, and must ever remain so. The thing, he said, 
was impossible, and all hope of it but a vain delusion. In five 
years from that hour Yelpeau, of Paris, amputated limbs and per- 
formed other grave operations whilst his willing patients were sleep- 
ing from anaesthesia. An American dentist, Dr. Horace Wells, of 
Hartford, Conn., conceived the idea of preventing the pain of sur- 
gical operations, and took the ether himself to have a tooth 
extracted. He devoted years to this discovery, with an enthusi- 
asm not excelled among ancient or modern inventors, but was 
ridiculed and abused. Pie was so disheartened by ingratitude 
that he died by his own hands in 1848. Dr. Morton finally 
died, discouraged, disheartened and penniless. His remains rest 
in Mount Auburn Cemetery, near Boston, " without a stone to 
mark the spot." What a homily could be read on this history ! 
What a lesson does it teach us ! 

There can be no doubt when we compare the symptoms occa- 
sioned by the use of the two an aesthetics, that chloroform is de- 
cidedly the more pleasant. Patients succumb to its influence a 
great deal quicker. There is none of the excitability which attends 
the use of ether, and it probably takes less than one fourth the 
time to chloroform a patient that it does to bring him under the 
influence of ether. In the one case the danger to life is compara- 
tively great, while in the other it is reduced to a minimum. The 
temptation to the surgeon to administer chloroform is very strong, 
when he knows — as is generally the case— that a patient will go 
through tiie various stages of intoxication if ether be given. 

Chloroform will very often bring a patient under anaesthetic in- 
fluence with extreme rapidity, but you scarcely know when your 
patients are in a dangerous condition if it be administered; and 
the deaths are numerous that can be attributed to its use. Al- 
though I have given chloroform a thousand times or more with- 
out accident, on two occasions I was on the verge of losing the lives 
of patients — once in Buffalo and once in St. Louis — and I have ab- 
jured the use of this agent from that time to the present as a 
general rule. I only use it occasionally. Ether produces all that 
we want, and if it is properly applied, can be made almost as 
serviceable as chloroform. If, before taking the ether, the patient 
is allowed to fast, and a stimulant given twenty minutes before 
the inhalation commences, the ether takes effect with much 

2 



18 ANAESTHESIA. 

greater rapidity. If jou do not desire to give stimulants in the 
shape of brandy or whi-key, you can give ten grains of the bromide 
of potash, which accelerates the influence of ether with most 
remarkable facility, and then there is no danger. I say that 
it is better to have the trouble, if an} 7 , with the patients alive 
on the table, and let them squeal, and vomit and kick if they like, 
and talk all kinds of nonsense, and occupy a great deal of 
your time — it is better to have your trouble thi n, than have it in 
a court of law afterwards, when the operator may be subjected to 
the most distressing self-reproaches if he has happened to lose a 
patient. I do not believe that any feeling ever passes throujh 
the mind of the conscientious surgeon which is more painful 
to himself, or renders him more miserable, than that of 
seeing a patient die on the table, while taking an anaes- 
thetic — particularly when he knows, or thinks, or believes that if 
he had used another agent the result might have been dif- 
ferent. There are, however, some surgeons who prefer to use the 
nitrous oxide to any other anaesthetic. It is an excellent 
method so long as it lasts, but it is too evanescent in its effect. It 
passes off in a very short space of time, and if you were to use it 
in general practice you would require a dray to go behind your 
carriage to carry the bags. For short operations it is very nice, 
but for tedious ones, it is not desirable, unless in a hospital where 
you can manufacture it, and then it is necessary to have it always 
made pure. 

This child has been twice tried with chloroform, but the effects 
were bad ; it lost its breath immediately ; therefore it is better to 
use ether, and take a longer time, if necessary. 

The parents state that this naevus was as large as a three cent 
piece when the child was born, and that when it was three or four 
weeks old the naevus was twice treated with a hot iron. This 
treatment is not desirable, as it is not so successful as the other 
methods I have referred to. 

(Dr. Thompson then continued the operation.) 
You will notice in this operation that the black threads come 
together, and the white ones also. We draw and tie the threads 
very tightly. 

This operation is a very serious one, and we do not know ex- 
actly what will be the result. We hope, however, it is for the best. 



£u*gwat &Mt, Qttobtt 12. 



Patrick Murphy, Aged Eighty -five. 

Ilere is a patient brought to us from Bridgeport, Conn., for 
treatment for Epithelioma, or Epithelial Cancer, which is one of 
the mildest forms of cancer, and affects often the lower lip, as 
in the present case. 

Some authors have styled this disease semi-malignant, or cancroid. 
In fact, it occupies a somewhat anomalous position, closely resem- 
bling innocent growths in cell structure, while in all other respects 
it is essentially malignant. Gross is inclined to think that it is 
"merely a form of scirrhus, modified in its character by the 
nature of the structure in which it occurs." It was formerly 
classed with lupus, but che later pathologists regard the latter as 
belonging- to ulcers rather than tumors. 

In regard to the causes of this disease but little is known. Ac- 
cording to Paget, only one twentieth of the cases are referable to 
hereditary taint. External injury, long continued pressure and 
local irritation, may serve as exciting causes ; for example, epi- 
thelioma of the lips may be induced by the pressure of the pipe, 
and the " chimney sweeper's cancer " is supposed to be caused 
by the irritation of soot lodged in the folds of the scrotum. 

Epithelioma attacks men more frequently than women, and 
seldom occurs before the age of thirty-five or forty. It gen- 
erally affects mucous and cutaneous tissues, especially the lips, 
tongue and faca ; bu" it may also invade deeply seated struc- 
tures, and be found in the bones, muscles, lymphatics, liver, lungs 
scrotum, anus and penis. 

It generally begins as a small wart, crack or tubercle on the 
skin, hard, movable, and tender on pressure. As it advances 
in growth it may assume several different shapes, sometimes con 
sisting of small rounded masses, half imbedded in the skin ; some- 
times projecting in warty, cauliflower-like excrescences of a florid 
color, and extreme vascularity. Again, the tumor may assume 



20 EPITHELIOMA. 

a conical shape, and be covered by a thick laminated scab, like 
syphilitic rupia; and, lastly, these morbid growths may be pen- 
dulous, and attached to the integument by narrow bases. 

On dissection epithelial cancer is found to consist of a firm, gray- 
ish or white substance, possessing considerable vascularity; 
unlike the varieties previously described, it has no stroma. 

According to Druitt, "Microscopical examinations show: 

1. The epidermic layer to be composed of epithelium, arranged 

in concentric layers around and between the papillae. 

2. The papillae and dermis are composed of white, intermingled 

with yellow fibrous tissue, everywhere abundantly infil- 
trated with epithelial cells, and with their nuclei and fibro- 
plastic matter. In the papillae, the epithelium is seen to be 
arranged symmetrically in concentric layers amongst 
the scanty fibrous elements, and this arrangement may 
penetrate to some depth within the cutis, from which 
elongated and imbricated rolls of epithelium somewhat 
resembling the heads of young asparagus, can be ex- 
tricated. 

3. Within the cutis and subjacent tissue the epithelium is 

found sometimes in concentric pellets like comedones 
or grubs, or inspissated contents of sebaceous follicles, 
sometimes in rings formed within obstructed ducts or 
follicles, but usuallj 7 in large, irregular quantities infil- 
trated amongst the fibres of the cutis and of the sub- 
cutaneous areolar tissue." 

The cancer cells which Druitt describes as epithelial, differ 
greatly from those of scirrhus and encephaloid ; in fact, they 
closely resemble the cells of pavement epithelium, they may be 
" round, oval, angular, fusiform or elongated," and they generally 
contain one or two nuclei, sometimes they are arranged in layers, 
and again they may be enclosed in cysts. Upon pressure, the cut 
surface of the cancer yields a clear serous fluid containing cells, 
nuclei, oil globules, and crystals of cholestearine. 

In its growth, epithelioma gradually attacks and infiltrates all 
surrounding structures. At length ulceration sets in, the surface 
cracks at several points, and there exudes a purulent, sanious 
fluid, which dries in a scab, this is soon thrown off as a slough, 
and we see a deep, excavated ulcer, with hard base, and rough, 



EPITHELIOMA. 21 

irregular edges, surrounded by warty fungoid growths. There is 
an exceedingly foetid, corrosive discharge, and sometimes profuse 
hemorrhage is caused by ulceration into a blood vessel. The 
sore shows no disposition to heal ; the disease gradually extends 
to adjacent tissues, and integument, muscles and bones are alike 
involved in the destructive process. The pain is sharp, burning 
and lancinating; the constitutional symptoms are well pronounced, 
but, as a rule, the cachexia appears later than in the other 
varieties.* 

After further examination of the case Prof. Helmuth continued 
as follows: 

Epithelioma is a disease affecting the cells of the papillae in 
different portions of the body, which become elevated, enlarged, 
readily bleeding, and finallj^ become ulcerous. There are two 
distinct species of epithelioma, one of which is cutaneous and the 
other of which is. deep. There is also another variety in which 
these growths become so large, and bleed so readily, and increase 
and grow in such a manner that they are called vegetating epithe- 
lioma. We find this class described under the name of cauliflower 
excrescence. A microscopical examination of the epithelioma 
discharge shows a closer resemblance to the epithelial scales of the 
body than those found in the malignant forms of cancer. Eecollect 
this one thing, before I go any further— that one of the differences be- 
tween cancer or a malignant tumor, and an innocent tumor, consists in 
the fact that the one is heterologous, or has tissues and cells not 
found ordinarily in the human body, while the innocent forms of 
tumors possess cells and structures similar to those found in the 
body. It seems as if this epithelioma were a variety betwixt the 
two — more malignant than the fibrous growth, yet not so malignant 
as the encephaloid, and other varieties of cancer ; and that its cell 
formation bears a closer resemblance to the healthy tissues of the 
body than any other variety of the so-called malignant formations. 

'An epithelioma is less likely to return than others ; and when 
operated upon quite early, if the glands are not involved and the 
patient is put under correct treatment afterwards, even if you 
cannot cure, you can postpone the disease for years. After the 
epithelial growth has been removed we continue internal 



* The description of Epithelioma here inserted is taken from " Helnmth's Sur- 
gery." 



ZZ CASE OF EPITHELIOMA. 

methods of treatment for the cure of the disease, or the eradication 
of it from the system. The old fashioned doctrine that cancer is 
hereditary or constitutional, begins to shake at its foundation. The 
microscope has begun to uproot many of these older notions ; and 
it is thought that in very many cases it can be proven that malig- 
nant diseases, and especially the different forms of cancer, are local, 
and that it is only after a time that the constitution begins to 
suf er ; in other words, that the toxaemia is the secondary, and 
the local manifestation is the primary cause, whereas we have 
been taught that there was a constitutional predisposition to cancer- 
ous disease, which had a tendency to render any little bruise result 
in some form of cancer. This is, however, uncertain as yet. 

Epithelioma may assume a most sudden and rapid growth, and 
may so undermine the constitution that life may be in danger, and 
death result from what is termed vegetating epithelioma or cauli- 
flower excrescence. 

This case of epithelioma undoubtedly arises from smoking a clay 
pipe. The pipe becomes very hot, dries away the tissues, and so a 
tendency to the disease is produced. It generally begins as a 
hard pimple under the skin — a hard nodule under the skin — 
which gradually comes nearer the surface, and is accompanied by 
peculiar stinging or burning pains, but not so much burning as we 
find in the true varieties of cancer. Finally, it ulcerates, and the 
ulceration is peculiar, consisting of elevated papillae, 

I think that, with the exception of the head of the penis, there 
is no more sensitive structure of the human body, than is the lip. 
I am now going to cut oat the side of this lip, and the question is, 
what structures do I expect to go through. The lips are formed 
of mucus membrane, and chiefly of the muscle called the orbicu- 
laris oris, to which muscle is attached a great many other muscles. 
For instance we have the anguli oris, the levator menti, the zyg- 
omatic major and zygomatic minor, the buccinator or trumpeter's 
muscle. These are all more or less blended with the orbicularis 
oris, and all assist in the free play of the lips, moving them in 
many ways. By the lips we mould speech; we use wind instru- 
ments, we talk, we sing. They perform various functions. If it 
were not for the lips we would never be able to give sweet kisses 
— and that is a very important function — necessary sometimes to 
be performed, but always better in private than in public ; be, 
sure, however, that you have a proper subject to operate upon. 



OPERATION FOR EPITHELIOMA. 23 

We have also in the lips the coronary arteries, which are 
branches of the facial. The facial artery comes up in this direc- 
tion, crosses diagonally and divides into two — the superior and 
inferior coronary ; and it is this inferior coronary artery which 
will be cut across in this operation. 

In removing epithelioma, it is very necessary that you cut out 
enough of the structure ; and it is really quite remarkable how 
much can be removed, and how good an operation can be made by 
taking out a large quantity of the lip. Those who were here at 
the last year's clinics will recollect that nearly the whole of the 
chin was taken off at one operation. I expect a patient here to- 
day from whom I removed the whole integument of the chin in 
extirpating a large mark which the girl had since her birth. 
Her mother was frightened by seeing a mouse, and when she was 
born she had on her chin an oblong, black spot, full of hairs, 
which resembled exactly the back of a mouse. It was taken 
out, leaving the vermillion border of the lip intact. It extended 
around the chin and covered so much of the surface that when 
the lips of the wound were drawn together the centre of the 
lips almost touched the nose ; but nature has behaved so well to 
the surrounding structures that the lip has come down in such a 
manner that you can now scarcely see any deformity. 

Here is a specimen showing the position of the muscles we shall 
have to cut through. Here you see the orbicularis oris, the zyg- 
omatic major and minor, the labii inferiororis and the angali oris 
muscles; and here you see the arteries — 'the facial coming up on 
this side, winding around the jaw and dividing into the superior 
and inferior coronary. 

The first incision that I shall make in this case is the one near- 
est the medial line. There is a good deal of hemorrhage about this 
operation. You see how the artery spurts. I will now make an 
incision directly down in this way. These arteries do not gener- 
ally require ligation. If you do not twist them the bleeding ceases 
when the cut surfaces are approximated. You can make very 
nice, clean work of this. It is important that these sutures 
should be taken down very deep. I shall take the stitch nearly 
a quarter of an inch back, and bring it out like that. Then draw 
up the lip as nearly as you can. 

We will now apply one part of calendula to four of 
water. Keep it on for about two days, and remove the lint the 



24 ANGULAR CURVATURE OF THE SPINE. 

second or third day. There is a good deal to be said about the 
removal of these pins. The time at which, they should be removed 
varies greatly. If you ieave them until suppuration is noticed 
around the heads, you may be sure that you will have a mark 
after wards, which about the face is always disagreeable, especially 
to a young lady. Therefore, on the morning of the third da}' 
you should try the pins by rotating them, and if you perceive 
that they are a little loose, do not wait for a drop of pus to be 
noticed, but cut the thread — don't untwist it — and then remove the 
pin by a rotary motion. It used to be the notion that in a suture 
one continuous thread should be used ; but I have found that in 
using a continuous thread you obstruct the circulation a good deal 
between the pins, and that it is better to take a single piece for 
each pin, and not to extend the thread from one to the other. 
The next case is 



Cecilia Fitzgerald, Aged Four Years. 

The mother states that the child has never been healthy ; that 
she had the whooping cough during the summer and the measles 
in January. That during the spring and summer she has had a 
pain and cramp in her hip. 

Here is the beginning of a disease which will result in deformity 
unless some remedy can be applied. You know the position of 
the spinal column, and that it is the axis which supports the trunk, 
and that it is made for its support. You know that it has four dis- 
tinct curves or arches, in order that it may the better support the 
structure. "When you examine the spinal column per se, when 
you recollect the number of bones that enter into its construction, 
and the variety of processes which come from these bones, as well 
as the wonderful motion which is permitted to the different parts 
of the spinal column, you cannot but be struck with amazement 
at the beauty of its mechanism, especially when you think of 
the motions of which it is capable, combined with its im- 
mense strength. On each side of the column we have certain 
varieties of muscles which should be symmetrical ; they are 
attached to the processes of the column ; and when these muscles 
act conjointly equilibrium is maintained. If, on the other 



CASE OF CICATRICES. 25 

hand, there is an antagonism between these muscles — if one set of 
them seems to have a tendency to draw the column to one side, 
then we have as the result, a lateral curvature of the spine. If the 
disease attacks the bodies of the vertebrae, and extends itself to the 
intervertebral substance, then there is a tendency in the front part 
of the vertebra to drop clown, and the spinous processes push 
directly backward. This deformity is called Potts' disease of the 
spine, or, angular curvature of the spiue. It arises chiefly 
from a carious condition of the bodies of the vertebras, wher- 
ever you find it, and is accompanied in a great many instances by 
disorder of digestion. "We find it chiefly in children having 
light hair and blue eyes, and a tendency to an enlargement of the 
glands — in other words, in scrofulous children generally. 

On looking at the back of this child, as you now see it, you 
would scarcely detect anything out of the way, but if } r ou take a 
profile view of it you can plainly detect the curvature. 

The mother states that when the child was seven or eight months 
old she fell down some steps, and ever since that time has had a 
tendency to carry her head sideways. 

There is one peculiarity about angular curvature of the 
spine which I wish to mention ; it is, that in the majority of in- 
stances you can trace it to some injury received in years gone by, 
but that if the child grows, and the general health is sustained, 
the disease is likely to be cured, leaving, however, some deformity. 

The object of the splint which I now apply is to lift the 
weight from the superincumbent part — from the sore, inflamed, 
irritable vertebras. There are two pads attached to it, which 
make a pressure on each side of the column. This splint must 
be worn night and day. 

The next case is 



Susan - Chrine, Aged Seven. 

(The mother states that nearly seven years ago the child was 
burned on the cheek by the side of the eye). 

This is a very peculiar case. This sore has for some time been 
suppurating and discharging, occasionally healing over and then 
gathering again. There are certain varieties of inflammatory 
action which seem to undermine the tissues from place to 



26 TREATMENT OF CICATRICES. 

place — in fact, to have a disposition to spread by reason of 
contiguity of surface. Here was an unhealthy action which 
began with a burn. Inflammatory action went on in one direc- 
tion and the process of repair went on with it in another. 
Inflammation covers not only the process of repair, but it covers 
the process of disintegration, and even the death of the part. 
At the same time that the pus is forming, there may be a repara- 
tive process going on in the same structure. We find this same 
thing in that variety of ulcers which are called serpiginous 
ulcers. They seem to extend in a circle, and as fast as one part 
heals another is destroyed. Now, the question is, what is the 
best remedy to apply ? 

(The mother states that the child has taken no medicine). 

There is no medicine that acts on cicatrices so well as si- 
licea. Wherever and whenever, under any circumstances, you 
can apply the appropriate homoeopathic medicines for surgical 
disease and cure your patient according to the homoeopathic law, it 
is better than operative interference ; true, it does not make such 
a brilliant appearance but it is better surgery, and it redounds 
more to the credit of the school than using the knife. 

Give this remedy of the 30th dilution three times per day. 



Jtatyiral Clinic of #rtok* U. 



Before the patients were introduced to the class, Prof. Helmut h 
having the week previous been lecturing upon the inflammatory 
process and its terminations, began the lecture as follows : 

Ulceration is that process by which a solution of continuity is 
effected in a living solid ; it is of much more frequent occurrence 
in the cellular and adipose tissue than in muscles, tendons, liga- 
ments, nerves or blood vessels. 

Formerly the Hunterian theory was generally received that 
such breach of continuity was effected by what was termed ulcer- 
ative absorption, or, in other words, that the absorbent vessels 
were chiefly concerned in the establishment of the process ; modern 
pathologists regard ulceration as the molecular death of a part — a 
gradual softening and disintegration of tissue, molecule b} 7 mole- 
cule ; the effete matter being mixed with purulent and other 
secretions, and thus carried out of the system. This process is 
generally a sequel to true inflammation, or connected in some de- 
gree with inflammatory action. 

If the inflammatory process continues, suppuration, softening, 
disintegration and detachment of the tissues in minute portions 
follow in succession the abnormal action ; the separated molecules 
become mixed with the pus, and are removed with the discharge. 
Ulceration is the medium between suppuration and gangrene. 

Ulcers are those sores that are produced by the ulcerative 
process, or, in other words, solutions of continuity in any of the 
soft parts of the body discharging purulent matter, found prin- 
cipally on the natural surfaces of the body, and originating 
frequently in a constitutional disorder. A sore discharging pus 
effected by ulceration is termed an ulcer. 

Now, merely to show you r gentlemen, how some cases in our 
practice are criticized, I will relate the following to you: 

On the 1st day of November, 1872, a sea captain aged sixty- 
five years, who had had scurvy, and who had been taking mercury, 
and who had visited many ports, was getting over a fence, and 
struck his shin ; a black and blue spot made its appearance, which 
continued to increase, this he doctored himself, putting on a little 



28 CASE OF ULCER, INFLAMMATION, CONGESTION. 

hot and cold water. On the 12th day of November he sent for Dr. 
H., who is a physician, seventy-two years of age, and has been 
practicing homoeopathy for twenty-five years and allopathy for the 
same time. He immediately told him that he thought it was 
a constitutional sore, and to adopt constitutional treatment, and 
to apply arnica and water. For ten days, up to the 22d of No- 
vember, the sore became worse, the black and blue spot began to 
suppurate and to bleed. Around and about the bottom of the ulcer 
three, or four, or five vesicles made their appearance. Then the 
doctor made a solution of nitrate of silver (he had practiced a 
good deal in the country, and he always carried a stick in his 
pocket) ; applied it around the sore and upon its surface ; it pained 
a great deal when the solution was applied. The ulceration then ap- 
peared to be stationary, the slough was apparently separating from 
the centre, and a yellowish pus was being discharged. But the 
patient became dissatisfied, and, through some outside influence, 
called in another surgeon. About the 1st day of January this other 
surgeon called, and what he did I don't know; I know the ulcer 
was discharging around the edges, and carbolic acid was ap- 
plied, and the secretion was immediakly arrested; the sore grew 
worse, and went on enlarging from the 1st of September 
to the 7th day of April, when the leg was amputated above 
the knee. The patient then sues Dr. H. for ten thousand dollars 
damages ; stating that it was the application of the nitrate of silver 
that brought about the condition which resulted in amputation of 
the leg. All manner of questions were put to me on my cross- 
examination, many of them foolish in the extreme, and having 
no bearing whatever upon the case, which, however, terminated 
favorably- for our side. 

Q. What is inflammation ? 

A. Inflammation, when fully established, consists in an engorge- 
ment of the capillary vessels, dependent on their diminished action, 
and the relaxed condition of their coats, together with more or less 
accelerated motion of the heart and arteries. From such an abnor- 
mal condition arise the well known characteristic symptoms — pain, 
heat, swelling and redness. (Dolor, calor, tumor, rubor.) 

Q. What is congestion ? 

A. Congestion is the preternatural increase of blood in the capil- 
lary vessels, or excessive local fulness of the small blood vessels — 
an unnatural accumulation of blood in any part of the body, or 
any subordinate system. 



CASE OF TRAUMATIC PARALYSIS — TREATMENT. 29 

Q. What is suppuration ? 

A. Suppuration is a pure process ofluxuriation, by means of which 
superfluous parts are produced, which do not acquire that degree 
of consolidation, or permanent connection with one another, and 
with the neighboring parts which is necessary for the existence of 
the body. Pus is not the dissolving, but the dissolved, i. e., trans- 
formed tissue. A part becomes soft and liquifies while suppura- 
ting, but it is not the pus which occasions this softening, on the 
contrary, it is the pus which is produced as the result of the pro- 
liferation of the tissues. 

Q. Suppose a part to be suppurating, and something is applied to 
that part which suddenly checks the formation of pus, is that a good 
or bad sign? Bad ; it drives the pus into the blood. Any sudden 
check of suppuration, set it down as a rule, is bad. 



Peter Caeteb, Aged Twenty -four. 

This man fell and injured the musculo-spiral nerve, so he has 
no use of his arm. 

Q. Have you applied electricity ? A. Yes. 

Q. How many times have you taken electricity ? A. Three 
times a week. 

Q. For how long a time ? A. From ten minutes]to a quarter of 
an hour. 

Q. Did you have any feeling as the current passed down the 
arm ? A. Yes, sir. 

Q. Do you feel it any more now than you did when it w r as first 
applied ? A. Yes. 

Q. Do you have any numbness in your hands? Yes, sir. 

Q. Does that sensation of numbness increase or diminish? A. 
It is about the same. 

Q. Are you sensitive to the cold — can you feel cold and heat ? 
A. Yes, sir. 

The sensory nerves appear all right ; he has a good appetite. 
He has been taking Ehus Toxicodendron three times a day 
This man has also a large red spot on his left leg. There ap- 
pears to be fluctuation in the tissue, but whether there is pus 
in it, or whether it is serum, it is pretty hard to detect. I have 



30 CASE OF SCIRRHUS. 

a notion it is serum. I believe that should the parts be opened 
with an incision, probably it would be a long time before the 
wound would heal. He should be allowed to keep himself quiet, 
and elevate the foot and keep it bandaged. The idea is to 
prevent local congestion. The part may be either strapped or it 
may be bandaged. I think I will strap it ; I will show you how 
to strap a sore. In applying plaster it is always necessary that 
it should be put on as smoothly as possible, and that each strap of 
plaster should be drawn uniformly tight; if you put on one strap 
tolerably tight, and the next one a little tighter, the one below loses 
its efficacy — it ruffs up. Now, this strapping is very excellent 
treatment in certain classes of indolent ulcer where the limb needs 
a great deal of support; it equalizes the circulation. In the first 
place, let me tell you about straps. In order to put straps on 
properly you must have the part shaved. You saw me try to put 
some straps upon a man who had his beard on, and the result was 
that there was no support to the part, and the wound separated. 
Where there is bristly hair, such as you have on the recendy 
shaved chin, the straps stick like the mischief, and give a great 
deal of pain when removed. In the first place, to cover that sore 
it must be perfectly dry. I will take the strap this way and let it 
go all the way over. I then reverse the manner of application and 
begin on the other side, allowing one strap to cross the other at 
the centre of the sore. The idea is to put them on alternately and 
make them come in a line. 



&e$¥?3tt»** 



Bridget McNally. 

This woman came to us with a cancer in her breast, and I cut 
it out She had it removed with the expectation of getting married. 
To the patient: 

Q. Did you go and do it? A. No, sir. 

Q. You have been a great deal better, haven't you, Jane ? A. 
Yes, sir. 

That wound looks very well; there is no indication of a return 
of the disease. From appearances I should suppose that there 
is a tendency to abscess, and I think that Hepar would be a very 
excellent medicine. I will give it to her in the 30th dilution. 



CASE OF 'NECROSIS OF FRONTAL BONE. 31 

She looked in a most miserable condition when she came here, 



now she seems to be getting better. She has an axillary abscess 
and a severe cold. 

Q. Can you put your hand to your head? A. Yes, sir. 

Q. Good appetite? A. Yes, sir. 

Q. You were very fond of a little drink once in a while, were 
you not? A. Oh, very fond, indeed. 



V**«fttp* ^f %U® ttitm*¥tt*4 



John A. Powers. 
John A. Powers, see page 9, arm. It has been two weeks 
to-day since he was here. Now let me see the other hand, 
one is about as dirty as the other. I will move his hand ; now 
put it out straight again; touch your head with it; now turn it 
over this way, now back. There is nothing so grateful to a 
patient with a broken arm as good bathing after taking the band- 
ages off. The arm is doing 1 well. 



V<*-e?<*j»ij» <oi 3F**»I*1 &$n&* 



Eobert Daily, Aged Twenty five. 

Q. "What is your name ? A. Robert Daily. 

Q. How old are you? A. Twenty-five }'ears old. 

This is an affection of the forehead, which has been troublesome 
since April, and was caused by being kicked by a horse. A Dr. 
Moore opened it. 

Q. Did any spiculae of bone come out? A. No, sir. 

Q. Have you been anywhere else for treatment ? A. No, sir. 

There is a peculiar appearance about a wound from which 
a piece of bone comes out, or where there is a sequestrum ; the 
parts are puckered ; seems to protrude. The appearance is like 
an unhealthy granulation, and there is puckering around it. This 
bone is exposed, I can feel it distinctly; but it is not loose, there 
appears to be a small piece of bone that wants to come out. (To 
the patient.) I will pull that out for you. 

Necrosis bears the same relation to the osseous svstem that mor- 



32 TREATMENT FOR NECROSIS, EPITHELIOMA. 

tification does to the soft parts. Caries is an ulceration ; Necrosis 
is the death of the bone. What is the difference between ulcer- 
ation and mortification ? The difference between ulceration and 
mortification is this — that in the ulcerative process there is no 
regular death en masse, but in mortification there is. It is aston- 
ishing how small a piece of diseased bone will give rise to ex- 
tensive suppuration ; a small piece of bone underneath the skin 
may give rise to a great deal of inflammatory action. I shall take 
hold of that bone once more ; I think it is not large, but it is fast. 
I find that is firmly attached. It would be a wrong process to take 
a larger pair of forceps and remove it. You must go home and have 
the part poulticed. I will give him silicea 30th, which he will 
take three times a day, and I think that by next Saturday the 
bone will be loose, and can be removed. Until the bone comes 
away there will be no uss in attempting to cure the wound. I pull 
it with all my might, but it does not move. He is to use simply 
a bread and milk poultice. 



Patrick Murphy, Aged Eighty-five. 

{Continued from page 19.) 

You all saw on Monday afternoon this patient was in a most 
excellent condition, and the reason that I removed the pins on 
this day, which is rather sooner thau it is usually done, was 
because there was beginning suppuration about the pins, and 
the threads were beginning to cut through. Whenever that 
happens, it is always a rule to extract the pins. We put on a 
strap, but that did not hold, because he had not been shaved. 
Then Dr. Boynton and others in charge of it applied silver 
sutures. Here is a man eighty-five years of age, and he comes 
here and has his cancer cut out because he wants to live. Life 
is sweet to all of us. 

Q. Do you feel better ? A. Yes, sir. 

Q. How old are you now? A. 85 years. 

Q. Where were you born ? A. In Ireland. 



A. H. B., Aged Nineteen. 

Q. What is your name ? A. H. B. 

Q. How old are you ? A. Nineteen. 

This young gentleman has had, since he was eight years old, 
Tonsillitis, or Cynanche Tonsillaris. 

This term denotes an inflammatory affection of the fauces, chiefly 
resident in and around the tonsils. It is ordinarily the result of 
atmospheric exposure, and is characterized by swelling and red- 
ness of. the back part of the throat, accompanied with difficulty 
of swallowing, impeded respiration, difficult articulation, marked 
alteration of the voice, fever and other ordinary constitutional 
accompaniments, according to the intensity of the inflammatory 
action. In the acute form suppuration often results, and we have 
(Quinsy. In other instances, as the present, the disease is chronic, 
and the tonsils remain enlarged. 

Q. Have you done much for this affection ? A. Yes, sir. 

Q. Taken a good deal of medicine ? A. Yes, sir. 

Q. Do you know what medicines you have taken, or who has pre- 
scribed for you ? A. My father. 

Q. He is a physician ? A. Yes, sir. 

You have taken, perhaps, all the homoeopathic remedies, and it 
is a question now, what shall we do in the case? Here is a gentle- 
man who has been under the treatment of a skilful physician, 
and still he is no better. 

The tonsils (tonsillae, amygdalae) are two prominent bodies, 
which occupy the recesses formed, one on each side of the fauces, 
between the anterior and posterior palatine arches. 

They are usually about eight lines in length, and four in width 
and thickness, but they vary much in size in different individuals. 

The outer side of the tonsil is connected with the inner surface 
of the superior constrictor of the pharynx, and approaches very 
near to the internal carotid artery. Its inner surface, projecting 
into the fauces between the palatine arches, presents from twelve 
to fifteen orifices, which give it a perforated appearance. These 
orifices lead into recesses in the substance of the tonsil, from which 
other and smaller orifices conduct still deeper into numerous com- 
pound crypts or follicles, the whole being lined with continuations 

3 



34 TREATMENT OF TONSILLITIS. 

of the buccal mucous membrane. The tonsils, therefore, consist 
of groups of compound muciparous crypts. They yield a mucous 
fluid which lubricates the fauces. The tonsils receive a very 
large supply of blood from many sources, viz., from the tonsillar 
and palatine branches of the facial artery, and from the descending 
palatine, the ascending pharyngeal, and the dorsalis linguae. The 
veins are numerous, and enter the tonsillar plexus on its outer 
side. Its nerves come from the glosso pharyngeal nerve, and from 
the fifth pair. 

Q. What are the fauces ? 

A. The posterior part of the mouth terminated by the pharynx 
and larynx. 

To the patient : 

Q. Do you snore at night ? A. Yes. 

Q. Pretty loud sometimes ? A. Yes, sir. 

Q. Your mouth is very dry in the morning ? A. Yes. 

Q. You have some sensation of choking in* your throat ? A. 
Yes, sir. 

Whenever he becomes cold there is an increase of saliva and diffi- 
culty of breathing. What should we do with this boy ? If he did 
not have to attend our lectures I would immediately cut out these 
tonsils ; under the present circumstances I should think he had better 
take mere. sol. 3d three times a day, and just before the holidays 
at Christmas times we will shave off the ends of the tonsils. He 
has been taking potash. There are a variety of medicines which 
are used with success in hypertrophy of the tonsils. The prepara- 
tions of mercury and potash, of course ; baryta., calc. carb., sulph., 
silic, lach., bepar., and others. But there is, also, a treatment 
for the removal of large tonsils without the knife, which has 
been very successfully employed in London, and which is sim- 
ple and efficacious, in that it does not confine the patient to the 
house. It is the application of the so-called London paste, pre- 
pared of equal parts of caustic soda and lime, moistened with 
a little alcohol. It must be kept in a well-stoppered bottle, since 
caustic soda and lime have a powerful affinity for carbonic acid. 
If exposed, therefore, to the air the causticity of the paste is lost. 
Various tests have also satisfied me that it is necessary to employ 
absolute alcohol in preparing it. 

In practice I proceed as follows : A quantity of equal parts of 
finely pulverized and well mixed caustic soda and unslacked 



CASE OF INDOLENT ULCER TREATMENT. 35 

lime is kept on hand. When an application is to be made to the 
tonsils, a little of the powder is put into a small porcelain cup, a 
few drops of absolute alcohol, which is kept near at hand, are 
added, the two are carefully mixed with a glass rod, when the 
paste is ready for use. The patient must be placed in a good light, 
a tongue depressor used, and the paste applied and allowed to re- 
main for several seconds, until an eschar be produced. Then the 
paste is washed off and the parts allowed to slough, when the 
paste must again be applied. Care must be taken that the paste 
is applied only to affected parts. It is likely, if too much is 
placed upon the rod, that some of it will drop off, which causes 
great excoriation. 

Dr. Morrell Mackenzie, of London, reports 200 cases in his own 
practice which he has absolutely cured. I think we will apply 
this preparation to this patient about once every three days. 

Note. — The treatment was carried on for some time ; and during the vacation at 
Christmas the outside of each tonsil was shaved off — a perfect recovery followed. 



J^4#lem* OT*e*a 



Jane K. S., Aged 38. 

There have been many classifications of ulcers attempted from 
time to time, and I think these may be simplified by dividing them 
into the simple, the indolent and the irritable ulcer. In the latter 
we generally have the symptoms which indicate a vitiated state of 
the constitution and disorders of digestion. We find the irritable 
sore in the upper ranks of society, among high livers, club men, 
men who dine out as a business, drink a great deal of wine and eat 
highly seasoned food. The edges of this sore are jagged, under- 
mined and serrated. The face of the ulcer is uneven and worm- 
eaten, the discharge is unhealthy, thin and sanious, the granulations 
are flabby and bleed easily, the blood being of a dark grumous 
color. 

The medicines that have proved most effectual in removing this 
form of ulcer are arsen., asaf., carbo-veg., lye, hepar, mere. -sol., 
nit.-acid, silic, mez., con., sulph., thuja, staphys. 

Grentlemen, look at this sore. You perceive the edges are ele- 
vated and smooth, not serrated, as in the form I have just shown 



36 CASE OF INDOLENT ULCER. 

you. You see that the surface is smooth, there are no granula- 
tions and that the color is tawny and gray. You perceive also that 
the margins are callous (this one especially so), and appear like a 
ring of cartilage. This is called by some authors "the callous 
nicer." You see also the condition of this patient — she is poor, and 
bears with her those characteristic marks of poverty which are too 
well known to us. If this patient could have her method of life 
changed, an immediate improvement would result. 

Q. Could you come into our hospital? A. No, sir. 

Q. "Why not ? A. I have to work, sir. 

Q. Have you a large family ? A. Yes, sir, small children. 

Q. Could } 7 ou keep your leg elevated in a chair, or could you go 
to bed for ten days or so ? A. No, sir; the times are too hard. 

You see, gentlemen, it is as I have anticipated; so, under these 
circumstances, we must do the best for her that we can. Before, 
however, I proceed with the treatment, let me say that you must 
not confound a scrofulous ulcer with the sloughing ulcer, which is 
more like what is termed "hospital gangrene.'' An indolent ulcer is 
an ulcer with irregular overhanging edges, with little pus with un- 
healthy granulations presenting around the edges of the sore, which 
extends into the surrounding texture. If you put your probe into 
the face of an indolent ulcer you will find the parts are callous, and 
the extreme frequency of this callosity has given rise to the term 
" callous ulcer.'' An indolent ulcer in a depraved constitution and 
on the lower extremities, where we have nine tenths of them, is 
very difficult indeed to manage; not so much on account of the 
position of the ulcer, but generally on account of the constitutional 
diseases which exist in the system. The sore is merely a manifesta- 
tion of this constitutional weakness, and, therefore, it is very im- 
portant, if you expect to cure radically an indolent ulcer, to adopt 
strictly constitutional measures. As a general rule, indeed you 
may set it down as a law, that grease of all kinds interferes with 
the curative process ; therefore ointments are bad for ulcers. 

In very many patients we have a condition of ulcer which is 
termed varicose.. Such an ulcer is nothing more nor less than 
an indolent ulcer. Sometimes an irritation takes place in a vein, it 
opens, and a certain amount of hemorrhage results therefrom ; the 
edges of the sore are overhanging and purple, they become some- 
what callous, and not at all sensitive to the touch, and this con- 
dition is termed a varicose ulcer. The supply of blood having been 



TREATMENT OF INDOLENT ULCER. 37 

cut off, the other veins attempt to do the work that should be done 
by this vein, and they also enlarge, or there may be other obstr ac- 
tion to venous return. The method of cure for such ulcers is to 
release the local congestions by destroying the varicose conditions 
of the part. Now, you must understand me, that when we 
speak of these ulcers I do not include in this classification the so- 
called specific ulcers, but, nevertheless, will mention here a particu- 
lar kind of sore, which is rather rare. It is similar to an in- 
dolent ulcer in a patient who has had scurvy. From the history 
of the cases which were observed in Dreadnaught Hospital, this 
ulcer begins with a black and blue spot under the cuticle from some 
external injury, which causes extravasation. After a certain num- 
ber of days a redness appears around the edges of the spot, and a 
dark red substance in the centre begins to raise up, underneath 
which an unhealthy suppuration is noticed. 

In the first place, to treat properly an indolent ulcer, if it is a 
possible thing, we want to support the part; it must be elevated, 
and should be thoroughly cleansed ; cleanliness is almost indispen- 
sable in the treatment of this form of ulcer, and the best way in 
which it can be cleansed is by carbolic acid spray, one part of car- 
bolic acid to 100 water. Then the limb should be supported with a 
roller, and the more the patient can be left on the back the better. 
For ulcers — old ulcers, where the parts are blue and overhanging 
— the best medicine is arsenicum, and the next best is carlo veg. 
With the proper applications you can cure these ulcers, provided 
the patient will always do as you direct. 

The reason ulcers are so difficult to cure is, because the patients 
are generally of the lower classes of men or women, who have to 
work for their living and are obliged to be on their feet ; or else 
the refugees of society, who care for nothing except their whiskey, 
and wander about the streets in a most pitiable condition. 

There are a great many local methods of treatment for ulcers, 
which I shall mention at the next lecture. We have electricity, 
we have the earth treatment of Hewson, and a great many other 
methods, all of which I hope to be able to give you at the next 
lecture, or as the cases present themselves at the clinics. 

What is scurvy ? Scurvy is that condition of the system, or 
a depraved condition of the blood, in which there is a tendency to 
fibrinous exudations in different parts of the body. At the same 
time there is a tendency to suppuration, ulceration and oedema, 



38 mother's mark. 

either in the gums or about the bones or different portions 
of the body ; the system suffers severely and the cure of the disease 
is brought about chiefly by giving the patient acids and vegetable 
diet, such as potatoes. You will find it principally among people 
who have not had a sufficient supply of vegetable food and acids, 
and who have lived on salt beef and salt pork. On board ships 
acids are generally provided to prevent the crew from having the 
scurvy. 

*4» > 



Dr. Helmuth (holding up a piece of flesh and hair in a bottle) 
said : There is the skin of a patient's chin ; this was a mother's 
mark. This girl's mother was four or five months gone in preg- 
nancy, and was very much frightened by seeing a mouse ; when 
the child was born, on the chin was this thing, covered with 
hair, and very dark hair it was. If you look at it sideways you 
will see it looks exactly like a mouse without a tail. The hair has 
turned white from being in alcohol, but it was perfectly dark when 
the growth was removed. The question arises, can the nervous 
influence of the mother be transmitted to a child ? I am just as 
certain that it can as I am that I am here. I know of a patient 
who was frightened with seeing a case of small pox, and her child 
was born with pustules on it. 



The first case to-day is that of Patrick Murphy, who was 
operated on two weeks ago for epitheloma of the lip. You 
will recollect that on the Monday following my last clinic the 
pins we;e withdrawn. It was rather an early day, but the union 
seemed so complete that I thought it advisable to withdraw the 
pins, and ordered adhesive straps applied. He was taken at night 
with a severe fit of coughing, which tore open the parts, and it 
was necessary to replace the pins. Last Saturday he was here, 
and other sutures used, but they came out. He came back on 
Tuesday, Dr. Thompson pared the edges afresh and applied new 
sutures, which are now to be removed. 

You will recollect how perfect the union seemed when those 
pins were removed on the third day. Of course, after the sutures 
have torn out, we have to be extremely careful. In plastic opera- 
tions like this, and in the operation for hare lip, the silk is often- 
times left after removing the pins, thereby affording considerable 
support. I have now removed the three pins, and the silk suture 
in the vermilion border of the lip. I should have taken the pre- 
caution to have had this man shaved, but now it is too late as the 
traction of the skin by shaving might break away the uniting 
points, I shall therefore leave his baard as it is, as it is now four or 
five days since he was shaved. 

I will now paint collodion upon the plaster. Very often after 
operations of this kind, and after that for hare lip, even after the 
parts have become almost perfectly united, I have known them 
torn apart by sneezing or coughing. Therefore, I usually take 
care, in operations of this kind in children, to paint the whole sur- 
face over with collodion. There are compressors which draw the 
parts together and take off the traction. In some instances incisions 
on the side are made to prevent the strain. 



John E. Jones, Aged 40. 
This patient comes from Poultney, Vermont. 



40 CASE OF SUBCLAVIAN ANEURISM. 

When you examine a patient you must always do so carefully 
and thoroughly. The greatest error that I ever made in my 
life in a surgical diagnosis was because I made it in a hurry. 
When I enter upon fractures and dislocations I will tell you of 
the mistake that I made — since which time, I assure you, I have 
been more careful, and have taken more time for my examinations. 

There is an epidemic in suicides sometimes, and there are epi- 
demics often in labor cases. Sometimes there seem to be 
epidemics in deaths. I have not had an aneurism to treat for a 
considerable time, and now I have four on hand. 

We will get this man's history, and that as accurately as 
possible ; and, if I do not mistake, this will prove a very inter- 
esting case. 

If-you listen, with your ear at the root of the neck on the right 
side, you will not only hear pulsation, but you will hear a puff- 
ing sound, which is called the bruit. That is the peculiar puffing 
sound that you have in an aneurism. 

An aneurism is an enlargement of an artery in some part of 
its course, the cavity of which communicates with the long diame- 
ter of the vessel. In other words, an aneurism is an enlargement 
of an artery — either spherical or longitudinal — and presents pecu- 
liar and unmistakable signs, such, as the pulsation, which pulsa- 
tion is simultaneous with the beats of the heart and also bruit 
We have a variety of aneurism, in which only one side of the 
tube is enlarged ; and we have a fusiform aneurism, in which the 
whole circumference of the artery seems to be involved. As 
a general rule, however, it is only one side of the vessel which 
is dilated, and we detect in it the symptoms of pulsation simulta- 
neous with the beats of the heart, and the bruit, or puffing sound 
which you have heard. 

Aneurisms, as a general rule, begin suddenly, and often result 
from some sudden shock or strain. A person may be predisposed 
to them by certain diseases incident to the arterial coats, as ather- 
oma, which is a softening or deterioration of the internal coats of 
the artery. 

The patient states that his attention was first called to the swell- 
ing last August ; that he has not had any difficulty in breathing, 
although he has noticed an occasional accumulation of phlegm in 
the throat, and that his voice has become more husky than for- 
merly ; he had been working with a derrick, but does not recol- 



CASE OF ANGULAR CURVATURE OF THE SPINE. 41 

lect that lie had been straining himself more than usual, but woke 
up in the morning and found a small lump, which pained him 
somewhat ; he has experienced no difficulty in swallowing ; but 
had slight cough. 

In the formation of aneurisms we always find what are called the 
active and the passive clot. As the blood is impelled through the 
aneurism by the beats of the heart, there is an effusion of fibrine 
which takes place around the circumference of the aneurismal sac, 
and this becoming partially organized forms itself into strata, be- 
comes of the color of currant jelly, and is termed the active clot In 
aneurisms about the aorta this clot sometimes becomes so large 
that the pulsation is almost indiscernable. Then, through the 
centre of this active clot, we have what is called the passive clot, 
or a clot which is thinner, and which allows the blood to pass 
through into the circulation. 

One of the methods of cure suggested by Sir William Fergusson 
is that of manipulation, in which this active clot is broken in 
pieces, and forced by the current into the channel of the artery. 

The subject of aneurism is possessed of so much importance, 
covers so wide a field in surgical literature, and has interested the 
minds of so many surgeons throughout the world, from a remote 
period to the present, that I propose to take up the subject in my 
next daily lecture (without waiting to arrive at diseases of the 
arteries in regular order), and, with this case before you, to lecture 
upon the subject of aneurism, properly so called. Then we will 
suggest the means of relief we think proper, after due consulta- 
tion. Several different methods have been proposed, and many of 
them followed with success; but it requires a great deal of judg- 
ment and thought — taking all the items of the case into considera- 
tion — to determine which method shall be adopted. I am glad to 
be able to bring this patient before you, because he seems willing 
and able to follow up the necessary treatment, and you shall see 
the result. 

ike Bf *&»* 

At the last clinic but one I showed you a case of Potts' dis- 
ease of the spine almost in its incipiency. This is a ease very 



42 CASE OF potts' disease. 

much developed. In the other case the disease was lower down 
the spine ; here we have it in the dorsal vertebra. It is not 
necessary for me to add anything by way of description of 
Potts' disease of the spine. I simply need to say that there are 
certain medicines which act internally, according to the homoeopathic 
principle, which have a tendency to arrest the disease of the bone 
which is going on. Mechanical treatment, in this variety of dis- 
ease — whether it is Potts' disease of the spine, or curvature of the 
spine laterally, or disease of the hip — is always of great avail — of 
as much service as a splint, in a case of fracture ; but there, also, 
are certain internal medicines which, if properly administered 
and persevered in for a length of time, will be of decided 
benefit. I have known Potts' disease of the spine arrested in 
its incipiency without the use of a brace, in cases where you 
could keep the patient prone in the horizontal position. But the 
trouble is, that a majority of the patients who suffer from 
Potts' disease are scrofulous children. This is an exception, 
I think. It is this very vitiated condition of the consti- 
tution which is so admirably relieved and cured by the proper 
internal administration of medicine. Therefore, while you should 
as surgeons look into and understand all the recent improve- 
ments which belong to the mechanical appliances in surgery, it 
is just as important, and even more so, that you should under- 
stand the application of those medicines which, properly admin- 
istered, will eradicate the predisposition upon which this disorder 
depends. 

The splint on this patient is a much better one than that 
which I showed you on the last case of Potts' disease. The ob- 
ject is to support the upper part of the trunk and keep the 
weight from resting on the diseased vertebra. The internal ad- 
ministration of medicine is of great importance. In the investi- 
gation we have to be guided as much by constitutional peculi- 
arities, by the looks of the child, by the previous history of the 
parents, and other objective symptoms, as by the result of any 
minute inquiries with reference to the increase or diminution 
of the symptoms, which the patient, because of youth, may 
be unable to answer. There are some medicines, such as petro- 
leum, phosphate of lime, phosphorus, iodine, calcarea-carb., sul- 
phur, mezerium, which may be used to advantage, but I have 
seen more good results from the use of phosphate of lime, and 



ANGULAR CURVATURE OF THE SPINE. 43 

from mezerium, than any other two of the medicines I have men- 
tioned. But do not understand me to say that these medicines 
are specifics for every case, because I do not. In these clinics I 
can only give you the names of the medicines from which you 
may select the special remedy applicable to a particular case. 
Therefore, I say that in a majority of cases I have found the phos- 
phate of lime and mezerium useful. In these cases the periosteum 
seems to be disordered rather than the bone itself; but when 
there is a good deal of pain, and. symptoms of fever set in, and 
the restlessness which follows any irritation of the system, you 
will soon discover the peculiar condition of the pulse which in- 
dicates an irritative fever. An irritative fever may be occa- 
sioned by any irritation going on in the system, from any 
occult cause. The patient wastes away, sweats, is pale, loses 
appetite, is fretful, peevish, the pulse stands at 120 ; he does 
not sleep at night and is depressed in mind. Whether it is 
a disease in the hip, or in the spine, or some other portion of 
the body, the symptoms point to an irritation in the system, which 
often begins in the first stages of Potts' disease, and before any 
local manifestation is looked for. Therefore it is that in these 
obscure cases, when you find an irritative fever, that the most 
careful examination be made in order that you may arrive at a 
correct diagnosis. Never be in a hurry to give a diagnosis. It is 
always a great deal better to wait, and especially never to put 
your ideas on paper until you are sure you are right. Many men 
have got themselves into a scrape by haste. When you are 
sure, then you may sign your name, but don't do it if there is a 
loophole by which somebody else can get hold of you and throw 
your diagnosis over. A man of inferior perception makes a good 
diagnosis in the advanced stage of the disease, and may thus, per- 
haps, outshine a more scientific or highly educated man who has 
seen the patient in the earlier stages of the same affection. Many 
a physician and many a surgeon has attended a patient straight 
through all the primary symptoms of disease, and has examined 
and studied up the case, yet could not tell exactly what was the 
matter, until the patient becomes dissatisfied ; and, perhaps, just as 
the disease develops itself, another doctor is called in, and re- 
ceives all the benefit of the diagnosis, because the symptoms are 
more perceptible to the senses. These are some of the injustices 
that may be done to the surgeon or physician. Therefore, I say that 



44 MISTAKE IN SURGERY — MISTAKE IN MEDICINE. 

when you find an irritating fever, or symptoms indicating a 
certain amount of fever in the system, be careful how you make 
your diagnosis. A mistake in surgery is unfortunate. A mistake 
in medicine is frequently never known. The difference is this : 
the doctor attends a patient, makes a mistake, and the patient dies ; 
he has been attended for the wrong disease, but he dies and no- 
body is the wiser. A surgeon makes a mistake — makes a crooked 
arm, perhaps, which is held up before a jury for his damnation, 
and the result is that thousands of dollars are claimed for the 
mistake. Death covers a doctor's errors, but a surgeon's are 
held up before an illiterate jury. These suits for malpractice are 
beautiful ! I do not know of anything that makes a man sleep 
sounder at night than a suit for malpractice. 



Newman Meyer, 11 Years Old. 

The father states : " About a year ago I noticed that this boy did 
not play as usual. A little later he would wake up at night and 
come down stairs, saying that he could not sleep. Then we took 
him to Morrisville and had him examined by a physician. 
The doctor said that he had the " sciatica," and blistered him 
on his back, near the hips. A little later we employed two 
physicians. They still called it sciatica, and cupped his back, and 
gave him medicines of various kinds. Then they changed their 
opinion, and called it " spinal irritation." The boy got worse, and 
then we had a doctor by the name of Kelly, who introduced him- 
self to me, and said that he was sent to me by my brother-in-law. 
He said that there were no symptoms of spinal irritation, but that 
it was a perfect case of sciatica. We then went to doctoring him 
again for sciatica, but without any good results. Then that doctor 
left him, and I didn't know what to do next. I noticed that when 
the doctors would stay away from me, and I attended him, that 
he would seem to be easier. About four weeks ago a doctor by 
the name of Waterbury, formerly from New York, asked permis- 
sion to come over and mend up my boy. Said he, "I know 
more than all these doctors; I have had a good chance; I have 
been in the city, and I know all about it." Finally I consented 



CASE OF LATERAL SPINAL CURVATURE, ETC. 45 

to have him come. He examined the boy. That was the first 
time the boy had been stripped and examined. He had been ex- 
amined only through his clothes before. The boy had, then, not 
walked for about ten weeks, but this doctor got him on his feet, 
and urged him to walk a little. After he examined him he said, 
"If old Dr. Sled was here he would call it 'worm palsy.'" Dr. 
Helmuth said, "I think the worms have not much to do with 
it, although they breed very fast in these cases." The patient 
continued : "He recommended an ' electrizing machine,' at first, and 
then he said that the boy would have to take opium continually 
and regularly. I did not like that, for I had about come to the 
conclusion not to give him any more preparations of opium, but 
he said that it would have to be done. Then he fixed up about 
a dozen pills, and put a little calomel in, so that they ' would not 
act upon the bowels.' I gave the pills to him that night, but the 
boy was worse. The following night I gave him the pills again, 
and still he seemed to be worse, and the same way with the next 
night. Then I went to see the doctor about it, and he told me to 
give him an ounce of opium — the clear stuff — the gum opium. By 
the time I got home my wife had given the boj 7 three of those 
pills, and he was still groaning with the pain. The pain is more 
severe at night than in the day time, and he cries a great deal at 
night. I then gave him a chunk of opium about as big as a 
a pea, in addition to the pills he had already taken. I usually 
went to bed as soon as I got home at night, and would sleep till 
about midnight, while my wife took care of the boy, and then I 
would get up and take care of him until morning. While I was 
in bed my wife gave him three more morphine powders, and he 
was still crying when I got up. I took him, then, and he con- 
tinued crying until daylight. My wife stated that she had also 
given him a double spoonful of paregoric to relieve his pain. He 
went to sleep about daylight, and slept all of that day and half of 
the next night. Then I said that that was the last opium he 
should take if he died for it." 

Dr. Helmuth said : This is certainly an obscure case. You can 
see from that boy's expression of countenance how he has suffered ; 
and you saw a moment ago, when I asked him to try to walk, 
what suffering the effort caused him. You must have respect for 
suffering whenever you see it; and when you see a human being 
Writhing the way that poor child did, and at the same time en- 



46 TREATMENT OF LATERAL SPINAL CURVATURE. 

deavoring to conceal it, for jour benefit, you ought to be thankful 
to him, as I am. 

One of the peculiar characteristics of bone disease is the increase 
of pain at night. 

From the examination I have made of this case I take it for 
granted that there must be some pressure upon the spinal cord. 
This is a very aggravated case of curvature of the spine, 
differing from the other cases that have been before us in the 
greater number of vertebra affected. If I mistake not this condi- 
tion will go on until an abscess forms somewhere. The peculiari- 
ties of the pain that he has now, the loss of the power of motion, 
the pain of walking, the sufferings increasing at night — all seem 
to indicate a disease going on in the bony structure, and I believe 
in the spinal column, causing pressure upon the spinal cord, 
producing a certain amount of paralysis, and necessarily causing 
the patient great suffering and emaciation. 

The question is, what can be done in such a case as this ? I 
think that this boy can be benefited. In the first place he must 
have a proper apparatus, which shall take the weight off the hips 
as much as possible, and relieve the spinal column. I believe 
that if we could get the appropriate homoeopathic medicine it would 
relieve him. I will give him mezerium and let you know the result 
I will give it in the 200th potency. Put one powder in a tumbler 
two thirds full of water, and give him a tablespoonful every two 
hours until this evening, and then, if the pain augments ; give him 
a teaspoonful every fifteen or twenty minutes. In the meantime, 
I will try to have some appliance made which will have a ten- 
dency to take the pressure from the spinal cord, and prevent further 
deformity. With a proper appliance to take the pressure off the 
spine, we can, with the appropriate homoeopathic medicine, greatly 
relieve the pain. There is no class of diseases in which medicines 
of the higher potency seem to act as well as in those of the nerv- 
ous system. 

-» » ■»» 

Eliza Thomas, 4 Years Old. 
(The mother states that the child has been suffering from pro- 
lapsus ani, and that the bowels have been protruding for three or 



CASE OF PROLAPSUS ANI — TREATMENT. 47 

four weeks.) The patient was exposed on the table, and a mass 
of bluish black intestine, four inches long, was found between the 
nates. 

It is wonderful that this bowel has not sloughed off before this. 
I do not know that I shall now be able to put it back as it should 
be done, but it must be returned pretty soon. The longer it is left 
out the worse the child will get. In reducing a prolapsed bowel 
you must do it gradually. With the fingers in this position, holding 
them as a cone, and lubricating them well, you push it up. (The 
bowel was then carefully returned.) When I get it in place I in- 
sert a sponge to hold it in position. It would be well to first soak 
the sponge in a strong solution of alum water, as that would 
have a tendency to make the bowels contract. I shall prescribe, 
as a medicine, nux vomica. I have had very excellent success 
attending its use in reducing prolapsed bowels. Administer 
nux vomica every two hours, and give only such articles of diet 
as will have a tendency to constipate the bowels. Give her 
chiefly boiled rice as food for the present. 



$m$m\ mmt of §mmbtx M, im. 



( Continued.) 

Dr. Helmuth said : The patient we had here last Saturday is 
doing remarkably well. He returned on the following Monday, 
and upon a careful examination I find that he has a subclavian 
aneurism on the right side, I think in the second portion of the 
artery as it passes behind the scalenus anticus muscle. You all 
know the danger that is attendant upon aneurism of this artery, 
and you all understand the difficulties (or you will very soon, for I 
shall tell you) of its ligation. The subclavian artery has never 
been ligated successfully in the first part of its course on the right 
side, and on the left it is almost impracticable. The operation, I 
believe, has been performed only once, and then by J. Kearny 
Kogers, of the United States, some years ago. His patient 
did not survive. Taking into consideration the anatomical situa- 
tion and the disastrous results that arise from cutting off so large a 
supply of blood, you will see what a hazardous, difficult and dan- 
gerous operation it is to tie the subclavian artery on either side 
in the first part of its course. In the second part of its course, on 
the right side, as it passes behind the scalenus anticus, it may 
be ligated, but it is difficult on account of the division of the muscle 
upon which lies the phrenic nerve, and also the close proximity of 
the internal jugular vein, a hemorrhage from which would almost 
certainly prove fatal. In the third part of its course the vessel may 
be tied, and the operations have been comparatively successful ; 
I mean, perhaps 43 out of 100 have recovered. When I get further 
along in the treatment of aneurism I will give you the exact statis- 
tics. 

These operations should never be undertaken, knowing how 
hazardous they are, until you have given the patient the benefit of 
every other known remedy. When a man takes an anaesthetic, and 
lies down on the table and surrenders himself to the sur- 



TREATMENT OE ANEURISM. 49 

geon's knife, to have one of these vessels ligated, it is almost 
like signing his death warrant. Therefore, I say, before any 
snch risk is taken, it behooves ns, as just men and good sur- 
geons, to give him the benefit of all the knowledge we have in his 
case before we subject him to a difficult and hazardous operation. 

The innominata has been t^ed, I think, about eleven times in all. 
To New York belongs the credit of having the first surgeon to 
tie this vessel. Valentine Mott was unsuccessful. I recollect 
reading an account of this case, and the intense interest that it 
presented to my mind. I remember the sentence in which, after 
describing how he had reached the innominata and the ligature was 
placed around the vessel, that he writes, "As I began tightening the 
ligature I never watched a human countenance with alternate feel- 
ings of fear and joy as I did that of the patient as I was drawing 
this ligature." He knew he was cutting off one-quarter the 
supply of the blood of the body, and he expected there would be 
great perturbation in the circulation, but such was not the case. 
Smyth, of New Orleans, has made the only successful ligature of 
the innominata, and he tied not only that vessel but the carotid, and 
checked the secondary hemorrhage, which came on from the sub- 
clavian, by means of small shot, which compressed the parts well. 
Hemorrhage, however, again recurring, the vertebral was tied and 
the patient recovered: 

I have ordered this patient to be given five drops of veratrum 
viride every four hours. His pulse is about 110, and I desire 
it kept down to 65 or 68. What does that do I It does not cut 
off the supply of blood, but it depresses the action of the heart, it 
lessens the vis a tergo ; it checks the flow into the artery and 
gives opportunity for a clot to form. If, instead of 110 strokes a 
minute, blood is forced into the vessel at the rate of 68 beats, 
you will see that there elapses between each beat a longer 
period, which affords time for the active clot to form. Besides this, 
I have ordered digital pressure of from five to eight minutes four or 
fixe times a day. It is perfectly unbearable at first ; the patient 
lies over and seems to writhe in agony, yet I fancy the tumor is 
harder, and that it is not as sensitive as it was, and that he 
suffers less pain. But I am not deluded by these appearances, 
and am prepared for emergencies. 

There are a great many other methods recommended for the cure 
of aneurism which it will be useless to try in this case. Suffice it to 



50 



OPERATION FOB SUBCLAVIAN ANEURISM. 



say, if, after having employed all tlie means in our power, the tumor 
increases, I will tie the subclavian ; but that will not be resorted 
to until we are positive that every other means is exhausted. 

This patient was removed to the hospital, and, after trying all 
means for relief without avail, Professor Helmuth tied the sub- 
clavian outside the scaleni.. The endeavor was made to reach the 
innominata; but a second aneurism, at the root of the carotid? 
pressed laterally on the trachea and forward on the sternum, to such 
a degree, that access to the great trunk was impossible. The 
patient died of rupture of the sac, on its posterior surface, on the 
eighth day. He was rapidly improving in health. The excruciat- 
ing pain had left his shoulder and arm, his pulse was fair, and 
temperature about 99. 

The accompanying cut will show the double aneurism which 
existed in this case and the surrounding structures. 




A — Innominata, 
"B — Subclavian, 
C — Common Carotid, 
D— Vertebral, 
E— Trachea. 



F — Larynx, 

G — Hyoid Bone, 

H — External Carotid, 

T — Subclavian Aneurism, 

J- Carotid Aneurism. 



3pfey«»<o*f*c 



A. X., Aged Twenty-three Years. 

The first patient that I shall introduce to your notice this 
morning is a case of phyrnosis, and a very bad case, too. 

Phymosis is congenital or acquired. Congenital phymosis is 
that variety in which at birth the prepuce is elongated. When it 
is acquired it comes from preternatural causes. This man stated 
to me that he had never been able to draw his prepuce backward 
any further than one-eighth of an inch (illustrating), and that 
lately he has had a very severe inflammation of the glans penis, 
and that then there was some discharge of foetid matter, and that 
since he has been unable to draw back the fore-skin at all. Now, 
in order to prevent fresh inflammatory action and adhesion of the 
under surface of the prepuce and the upper surface of the glans, 
I propose to circumcise him this morning. I can simply slit the 
prepuce with the scissors ; it is a very easy operation, but it does 
not make as nice a cure. A man does not enjoy the appearance 
of a slit prepuce. In this instance I shall cut off the projecting 
part of his fore-skin ; you will find, then, that there will be an ex- 
posure of the mucous membrane. I shall snip it at four corners 
and turn it over and stitch it. This is a pretty thick prepuce and 
we will have a little more hemorrhage than usual. 

Now, you see, I hold the prepuce forward in that manner, and 
the glans away from it ; then I take a knife and shave it off at 
the top. There is the mucous membrane ; the skin is off; the 
mucous membrane is not touched yet. 

Now we divide this and turn it up on end ; I shall then trim it 
down on one side, and take the other end off' by paring it upward. 

Then I make nicks in it in four places around, as I shall show 
you when I get through, and loosen it, thus making a kind of 
flap or curtain ; we just put a stitch in each one of these and the 
operation is finished. 

There are many different kinds of operations proposed for the 
relief of phymosis, but this will make the nicest cure, because we 
have the mucous membrane turned over. It is very important 
in these operations that you remove enough of the mucous mem- 
brane, because, if you do not, you will have contraction; unless 



52 OPKKATIOX 1'OK PHYMOSIS. 

you slit the membrane, as you have seen, in four or live places 
and then turn it over well, you will very likely have retraction. 

Another method of operating for phymosis is by forcible rup- 
ture of the mucous membrane. You all know that it is that 
tissue that makes the trouble; it is not the integument. The 
skin is generally flaccid. It is the mucous membrane that has a 
tendency to contract. Dr. Hutchinson, I think, proposed forcible 
rupture of the lining membrane. A pair of forceps with long 
blades is passed between the prepuce and the glans and then 
opened forcibly and withdrawn with the blades extended. You 
will see, as the blades open, a rupture takes place of the mucous 
membrane and the disease is for the time relieved. But we find in 
this operation, especially in children, there is great likelihood to 
contraction; therefore, it is better to perform the operation as you 
have now seen. There is an instrument called the circum- 
cision forceps, which is made for putting in these threads, such as 
are being introduced by Dr. Thompson, which also brings the 
membrane and skin together before you make the incision. I for- 
merly employed them, but I have come to the conclusion that the 
better way is to cut off the skin entirely, then trim the mucous 
membrane, slit it up and turn it over. By such a process there is 
no such tendency to contraction. 

The very contrary of phymosis is paraphymosis, which is a 
condition, in which the glans penis is constricted by the prepuce. 
In other words, the prepuce is pulled backward and contracts 
around the glans. I don't know a more disagreeable position for a 
young man to get into, or an old man either, than to have his prepuce 
drawn tightly around the corona, and not be able to return it. 
The part begins to look very angry and gets rather blue, and the 
man begins to be of the same color and to fear for the organ itself. 
It is astonishing how much love the human race do have for 
that part of their body; they had rather lose any thing else than 
part with that. There are several modes of reducing paraphy- 
mosis. In the majority of instances no operation is required. If 
you oil your thumbs and the prepuce and the under surface 
of the glans, and take the penis between your two fingers in 
that manner (illustrating), and place your thumbs on the glans 
penis, you will be able to bring the parts in situ. 

Now, this patient certainly has a very much better looking 
member than he had before, and he will be able to see more of it 
than he has ever done in all his life. 



CASE OF SYNOVITIS — TREATMENT. 53 

Sometimes, in operating for phymosis,we remove the stitches a 
little too soon, from some irritation in the system or from some 
other cause, an inflammatory action is set up in the lips of 
the wound, between the mucous membrane and the skin, and 
unhealthy granulations and fungoid growths appear, which give 
a great deal of trouble. Therefore, it is well not to remove these 
stitches for at least a week. 



n 



Josephine Lyon, Aged Five Years. 

History of Case. — Here is a lame leg ; a sore appeared upon 
the ankle, and the mother put something upon it to draw it ; 
then pus oozed from it ; it has been discharging pus and serum ; 
the probe goes into the joint; her physician had given her silicea, 
but there has been no change in her condition ; the patient walks on 
the affected foot; the attending physician had not seen her father 
before her appearance in the lecture room, a little boy having 
come with her every time. 

Prof. Helmuth said : This is a case of synovitis — inflammation 
of the synovial membrane, which lines the cavity of the joint, 
and this membrane is liable to inflammatory action. We gene- 
rally find that synovitis comes from an accident, or a bruise, 
or an injury of some kind. This child, her father says, turned 
her foot, which is a very common cause of synovitis in children. 
There is no disease that seems to be more curable by proper in- 
ternal administration of medicine than this one. The trouble is, 
that the child walks too much. Every time she places her foot 
down the weight of her body falls on the diseased membrane, 
and when she moves it friction results. Therefore, I say that 
perfect rest, combined with the internal administration of proper 
medicines, should be used immediately and continued. Dr. 
Thompson has had her in charge two or three months, and the 
treatment has been most judicious, but she will not get better un- 
less she is kept still. She will continue with the medicine she 
has been taking, and come here again in three weeks. 

Synovitis is generally curable, provided a certain amount of rest 
is obtained — but if, on the other hand, the inflammation is allowed 
to extend to the cartilages, we have a very serious disease, 



54 CASK OF AND OPERATION FOE EPULIS. 

viz., an ulceration, which it is a very difficult matter to cure. The 
cartilages are supplied with blood from tufts of vessels lying upon 
them, and friction after bruising is liable to produce inflammation, 
therefore it is, that rest is necessary, if you wish to restore the part 
to its original integrity. The pressure and friction which belong 
to motion have a tendency to keep up the irritation of these artic- 
ular cartilages. 



SjmUs* 



John Bowden, Aged Eighty four Years. 

History of case. — Health pretty good ; swelling in the mouth, 
growing apparently from the gum. 

After an examination, Prof. Helnmth said : Here we have a 
fibroid tumor or fibroid growth, properly so called ; it is gene- 
rally pedunculated and not sessile. A sessile growth is flat and 
broad. This is a fibroid tumor of the gum, which is called epulis ; 
it bears a strong resemblance in its forms to myeloid growths, or 
that variety of tumor known as a myeloid tumor, and which, also, 
generally springs from the surface of the bone. As you see, these 
tumors can generally be handled with very little pain to the 
patient, and they can easily be removed by scraping to the 
bone. I shall take a pair of scissors and cut this off, and if 
the bone is diseased I shall scrape it. It will not take long to 
excise it. Or, we may put a ligature about it and let it slough 
off. I think it is better to cut it off and then apply nitric acid. 
This variety of growth sometimes attains great magnitude ; some- 
times they not only involve the gum itself, but they extend into 
the face and cause the eye to protrude, and sometimes take away 
a portion of the bone. It is pretty difficult, in the earlier stages 
of these epuli, to distinguish between them and a myeloid forma- 
tion, which is more cancerous in its nature. This has been grow- 
ing about a year. Epulis is very likely to grow from the socket 
of tooth, and it often appears on the alveolar process. It is a 
disease generally of middle life, although we some times find it in 
the aged. In this case there is a broken tooth, from which there 
arises a certain amount of irritation, and from that irritation the 
fibrous growth rapidly increases. (The tumor was cut off and the 
bone scraped.) 



ci*n *»&$#**» 



Miss Van Houghton, Aged Twenty Years. 

Prof. Helmuth said: Through the kindness of Dr. Houghton I 
have a very important case to show you, which I shall take notice 
of quite at length. 

We have every reason, gentlemen, to feel proud of our clinics, 
and to feel thankful to those of the profession who interest them- 
selves in our behalf. The four cases that will constitute this clinic 
are all interesting ; some of them, indeed, not often encountered. 
Aneurism of the subclavian, phymosis, epulis, and cleft palate 
furnish sufficient material for a course of lectures. I must, there- 
fore, be brief and practical in my remarks. 

Perhaps there is no subject which has interested the attention of 
surgeons much more than this, of cleft palate. It may seem a very 
simple thing, whereas it is a subject of a very great deal of impor- 
tance. The difficulties that surround it are numerous. We have 
not only the miserable condition of the patient, but we have also 
the uncertainty of the means of relief, as well as the fact that, after 
these operations, the condition of the patient is not always im- 
proved. 

We will look at this lady, as I will have her go round and 
show you the cleft palate, and then I will call attention to the anat- 
omy of the parts and to the different practices recommended for 
its cure. 

The patient was here introduced. 

You will recollect that the hard palate is used not only in 
deglutition but in enunciation. Both the hard and the soft 
palate not only serve as a fulcrum for deglutition, but mould 
the sounds that come from the larynx and give them sweetness 
of tone and reverberation. The first sound of G, as in "go," is 
always hard to articulate with a cleft palate, simply because there 
is no fulcrum upon which the tongue can rest, as you will see 
in this case, although this is an imperfect cleft. If we examine a 
foetus at the sixth week the whole cavity of the mouth, the cavity 
of the nose, and the cavity of the pharynx is one vacuum. At the 
end of a few weeks more, there seems to grow from the margin of 
this cavity a membranous partition, which divides the nares above 
from the mouth below. Then from this membranous formation a 



§0 CASE OF CLEFT PALATE. 

vertical partitional membrane appears to come down at right 
angles, which divides the two nares, the one from the other. As 
these two sides seem to approach each other, there is a triangular 
space left on either side, which is afterward filled with bone from 
separate points of ossification, making what are termed the inter- 
maxillary bones. First we have this rounded cavity ; then from 
the sides of this cavity, approaching each other, and dividing it 
into two, we have a membranous partition formed, which seems 
to grow from the circumference towards the centre. 

As this nearly closes, another membrane takes a vertical direc- 
tion, dividing the nares. Thus the vertical membranous partition 
and the horizontal one come nearer and nearer together until we 
have the roof of the mouth almost complete, except the centre piece, 
which is afterward formed, and through the medium of the inter- 
maxillary bones. These grow from separate points of ossification, 
and if there is an arrest of development in the hard palate, if the 
process of ossification does not go on as it should, and if there is any 
deficit in the location of the intermaxillary bones, then we 
have a cleft formed in the mouth, and this is termed a cleft 
palate. If it is a perfect cleft it is generally associated with an- 
other arrest of development, which is called hare-lip. I show you 
here the superior maxillary bones, and by placing them together 
you will see that this groove in each palate process, when the two 
come together, make a foramen, called the foramen incisivnm, 
which marks the posterior boundary of the bones we are consider- 
ing, which are perfectly formed about the eighth or ninth month. 
Not only have we the palate processes of the superior maxillary 
bone entering into the formation of the hard palate, but we have 
the palate processes of the palate bones, which form also the back 
part of the roof of the mouth and floor of the nares; they project 
backward into the mouth, and terminated in a small process, which 
we call the posterior nasal spine; from this, there are two muscles 
which hang down and form the uvula; so much for the hard pal- 
ate. Next we have a curtain which is suspended from the hard 
palate, which is called the soft palate, separating the mouth in 
front from the pharynx behind, which is essentially muscular in 
structure, and which performs certain ofiices in the acts of degluti- 
tion and also in articulation ; the muscles that enter into the 
formation of this soft palate are the levator palati — the elevator 
of the palate — and the tensor palati, or the tightener of the palate. 



CLEFT PALATE. 57 

I liave drawn on the blackboard a couple of diagrams in order to 
let you see as nearly as I can the relation of the parts ; I have 
endeavored to show here a view of the bones looking from behind, 
as if the head were sawn off directly at the posterior nares. (Ex- 
plains diagram.) Arising from the under surface of the eus- 
tachian tube and from the apex of the basilar surface of the 
petrous portion of the temporal, we have a mass of muscular fibres 
that come down and pass above the superior constrictor, thus 
forming that portion of the soft palate. The apex of the petrous 
portion of the temporal bone being a fixed point, you will see, 
when deglutition takes place, the action of this muscle is to draw 
up the palate, therefore it has its name, the levator or elevator of 
the palate. On the other side, I have endeavored to give you the 
two muscles — one the tensor palati, and the other the levator pa- 
lati just mentioned. The tensor palatiis a small muscle which 
lies outside the preceding and is attached to the base of the in- 
ternal pterygoid plate, and winds around underneath the hamular 
process, and has a tendency to draw the muscle tight. (Explains 
the diagram.) JSTow, you see, these all being fixed points, when- 
ever the act of deglutition takes place, as you swallow, the palate 
is drawn up. There are two other muscles which I will show you 
directly. Look now at the patient ; when she makes an effort to 
swallow, you see the two sides of the cleft come together. I would 
like to ask you how it comes, that, with the tensor jpalati to lift 
them up, and the circumflex jpalati to pull them apart, that, 
when she swallows, instead of separating, the clefts came to- 
gether especially when we have the palato pharyngeus and the 
palato glossus muscles having a tendency also to draw the parts 
downward and outward. These dots represent the fixed points to 
which these muscles act when they contact in unison. 

I will tell you why — and the observation that I am about 
to make had eluded the most accurate observation of most 
distinguished surgeons of the times, until Sir William Fergusson 
discovered the reason. It was strange that Koux, Warren, and 
^elpeau, and those men who carefully examined into this sub- 
ject, never seemed to arrive at the cause of this peculiarity. 
The reason is this : you have all seen a horse put down his head 
to drink at a trough, and you have seen, as he drinks, his cesopha- 
gus contracting from above until the water gets down. Wow, there 
are three muscles, circular muscles, that enter into the construction 



58 TLKFT PALATE. 

of the pharynx, and the superior one of these is termed the supe- 
rior constrictor. (Illustrating.) Let that represent the basilar 
process of the occipital bone, and let this represent the larynx, 
which is cut open from behind; and that represent the posterior 
nares, and this represent the palatine muscles; here we have the 
levator palati, the tensor palati, the palato pharyngeus which come 
down on the pharynx. These muscles are all associated above 
with this muscle which is cut open, and which is the superior con- 
strictor of the pharynx. These muscles all being connected with 
the last named, when swallowing begins to take place the 
edges of the cleft come together from the action of the superior 
constrictor. 

I have entered a little minutely into this description of the 
anatomy of cleft palate, because, after the cleft is closed, these 
muscles, the tensor palati, the levator palati, the palato glossus, 
and the palato pharyngeus then act in unison, as they ought to have 
done, and the tendency is to stretch the palate apart. Therefore, 
it is necesaary to divide the levator to avoid traction upon the 
sutures. 

There are five varieties of cleft palate. The first, when there 
is a cleft on each side of the nostril, through the hard and soft 
palate, associated with hare-lip. This is the most severe variety. 
There are two clefts, one generally in each nostril ; you never, or 
very rarely, see a cleft in the centre. If the intermaxillary bones 
are only partially formed, you will often find there is a protrusion 
in the centre of the cleft. 

The second variety, is where there is a single cleft through the 
alveolar process, extending backward through the palate process 
of the superior maxillary and palate bones, and also through the 
soft palate. 

Then we have the third variety, in which the front of the mouth 
is all right and the parts intact, but there is a cleft extending 
through from the posterior portion of the alveolar process back 
through the entire palate, hard and soft. 

The next variety is that which we now have under considera- 
tion, when but half of the bony palate is involved, and the entire 
soft palate. 

The last variety is that in which the soft palate alone is in- 
volved. 

For the relief of these deformities a great deal can be done. Five 



STAPHYLOKAPHY. 59 

or six years ago it was considered almost impossible to close a 
cleft palate in a young subject, and many times I have suggested 
that patients be taken away and postpone the operation nntil they 
attain their growth. But late observations have convinced many 
■surgeons that early operations are rather preferable than those that 
are deferred; because, if you have to deal with an entire cleft 
palate, where the bony surface of the palate is involved, in early age, 
the bones are not ossified, and there is not so much deposit of 
calcareous matter; they yield readily, and, since chloroform can be 
given, such operations are preferable; It formerly was supposed 
that. you could give no chloroform or ether in this operation, on 
account of blood dropping down into the throat, but it has been 
proved that anaesthetics may be administered and restoration of 
the palates of young children may be effected. 

The operations for cleft palate are performed with knives with 
long handles, and the patient must be able to tolerate a foreign 
substance in the mouth for a considerable time, and it is well to 
educate them in that regard. Then the first step is to pare the 
•edges of the cleft. Yon take hold of one side with long forceps 
and with a knife, generally bent at right angles, you shave off the 
margin; then you seize one of the margins and draw it out, 
and you pass your knife through, inward and upward, and divide 
the body of the levator palati muscle. You can feel the process 
in the back of your own mouths if you try, and if you enter the 
knife a little anterior to the second molar tooth, in the upper 
jaw, and pass it upward and inward until its point appears in 
the cleft by moving the handle upward and downward, 
you will make a very little incision in the mucous membrane 
and you will divide the levator palati almost completely. Then 
it is necessary, in a majority of instances, with a pair of blunt 
scissors to divide the posterior and anterior arches of the 
pharynx. You will see how this will relax the edges of the 
cleft and how they will drop down. Then stitches should be 
applied. In an extensive cleft of the palate, you must never 
try to close the hard and soft palates with one operation. In the 
first place, it is exceedingly tedious; second, the patient is wearied; 
and in the third place, the parts have not become accustomed to 
the traction, and thereby may readily tear out. When you close 
the hard palate and you find that you cannot bring the edges 
of the parts in apposition, then you must take a long knife with a 



60 . HIP-JOINT DISEASE. 

rectangular blade and loosen up the tissue from under the surface 
of the hard palate for a considerable distance, and if necessary > 
employ lateralincisions on each side, in order to make the flaps ap- 
proximate, but in no case should you make severe traction on the 
sutures or in the flap unless it almost comes together. I think this 
operation was advised by Warren, of Boston, but lately, within the 
last few months, Sir William Fergusson, having found great diffi- 
culty in closing thebony portions of these gaps, has devised another 
method of closing the hard palate, which he states is more suc- 
cessful than any other — that is, after having previously closed the 
soft palate, he introduces through the nostril a flue chisel, and 
divides the bony structure in such manner that the edges of the 
wound may be more readily brought together. 

I hope you will recollect the anatomy of these parts, the means 
of operation, and the different steps thereof, and we will endeavor 
to perform it for you at an early date. It is an operation that 
cannot be seen very well by the class ; it is too tedious and too 
prolonged. I would like you to recollect tins anatomy, because 
it is important in your practice. She was removed and operated 
upon in the hospital 

August Sissman, Aged Twelve Years, Going on Crutches Two Years. 

Prof. Helmuth said : In the last stage of hip disease the foot is 
turned inward; in the second stage it is turned outward. In the 
first stage there is not much change. This foot business is a great 
bugbear to students, and it always gives me great pleasure to give 
them such a case. 

In ninety-nine cases out of a hundred — and I do not believe I 
say too many — you will find that hip disease has been occasioned 
by injury ; this is the experience of medical men. But the injury 
is often so slight that the parents of the child, or those who have 
charge of him, do not notice it. A fall on the hip of a healthy 
child will be very apt, if it is not looked after, to produce this 
affection. Hip disease was formerly considered a scrofulous dis- 
order; it used to be considered a strumous affection of the joint,, 
but statistics prove beyond a doubt that it is persons who are not 
scrofulous — the most wild harum-scarum boys and girls, who are the 



HIP- JOINT DISEASE. TREATMENT. 61 

most likely to be afflicted with the disease ; and, when you trace 
the case, you will find that there has been at some time a bruise, 
or an accident has occurred. 

£In this case the father said the child fell from a ladder, a distance 
of one story, when he was seven years of age, but did not 
mind the fall. When he came to grow in years his hip 
began to swell ; it enlarged a few months after the fall ; he ex- 
perienced a good deal of pain during the night, and the leg 
and hip then showed marks of extensive suppuration with 
several openings.] 

In all cases of developed hip disease, one of the characteristic 
peculiarities is that the gluteal fold of the affected side is lower 
than the other. In this case, there is not anchylosis, which makes 
& great deal of difference. You know if inflammation extends 
within the joint, after a time suppuration results, and abscesses 
open in different parts of the thigh, sometimes above and some- 
times below. Then Nature attempts the cure by anchylosis, by 
which I mean a stiffening of the joint. It may be spurious, 
formed by the ligaments and tendons, or it may be osseous. If 
the muscles around the vicinity of the joint can be made promi- 
nent by an attempt at motion, even if there is apparently no mo- 
tion of the joint itself, then you may be sure you have false anchy- 
losis. If, on the other hand, the muscles cannot be drawn into 
any degree of tension, and the tensors do not seem to rise up, 
then you have true anchylosis. One method of detecting the true 
from the spurious is the absence of pain after manipulating in the 
synostosis, and the contrary in spurious. 

There is a good deal of chance for this boy, but there is no 
hope of his ultimately recovering with a good leg. He will be a 
cripple, but I think, perhaps, he will get well of this condition and 
be able to move with moderate facility. But there must be care 
that he does not move too much. Let him be brought here this day 
three weeks. Give him silicea of the 30th, a powder every night. 

It is a question upon which I have not made up my mind, 
how much extension of the parts will do for him. Generally, 
traction relieves the pain. You see, as I pull the leg down, 
he does not suffer. It shows that the pressure is taken off' 
from the head of the bone, and that the caput femoris, 
although it may be diseased, is painful when pushed into the 



62 HIP-JOINT DISEASE. 

acetabulum. As I thrust the leg up, you see it causes him pain. 
Give this hoy good, wholesome food, and give him the powders 
regularly. 

In the mean time, before the three weeks have passed, I will take 
pleasure in lecturing to you on this subject. There is nothing like 
impressing upon your mind, through all your senses, the differ- 
ent cases that are lectured upon. Therefore, I shall be able to go 
on with these cases with much more facility to myself and better 
understanding upon your part. In the mean time, I will see 
that appropriate mechanical treatment is provided. 



JJwgita! Clinic 0f gowmbcv Hih, 1874, 



Deg dOit#. 



John Spellman, Aged Twelve Years. 

Pkof. Helmuth : 

Here is a simple abrasion caused by the teeth of a dog. If it 
were now the heat of summer, and the hydrophobia mania was 
as rampant as it was during that season, we might, perhaps, con- 
sider and treat this as a case of incipient hydrophobia. A slight 
scratch -like this sometimes results very seriously. Even when 
the dog has no symptoms of rabies, if the constitution is impaired, 
the bite may, and sometimes does, give rise to very serious 
consequences. There seems to be a poison in certain varieties 
of saliva, which, when inoculated into the system, gives rise to very 
great disturbance. In fact, I have never yet known the bite of a 
man, when indicted upon the finger down to the bone, that did 
not result so seriously as to require amputation of the linger. 
It is astonishing how poisonous all these bites become, even in 
healthy persons. Among the lower classes, there are those who 
are so frequently engaged in fighting, that they become brutal, 
and snap like the lower animals ; and their bite seems to be very 
poisonous. I have amputated more than one finger for such a 
wound. I have seen very disastrous consequences result from such 
bites or simple scratches, because the constitution is out of order, 
or there appears to be some process going on in the blood tending 
to spread the virus through the system and produce bad results. 

We have cauterized this wound, so that if there is any poison in 
the bite it may be neutralized. The boy will be brought here 
again, and his constitutional symptoms will be carefully noted, 
and treatment applied accordingly. I think, however, that 
nothing further in this case will be required, but because it now 
appears so simple, there is no reason why it should not be care- 
fully scrutinized. 



3p aroayefeia— Wfcii I o w* 



Mrs. Hall. — Felon on the Finger. 

History of Case. — [This disease appeared without any ap- 
parent cause. Does her own w T ork, and has her hands much in 
hot soap-suds. At first it had the appearance of a "run around," 
and the skin btoke, and there was severe itching and burning, 
and the swelling seems now to be extending into the arm.] 

Prof. Helmuth. — A felon, as we properly understand it, is an 
acute inflammation which affects the deeper tissues of the fingers 
and toes. Felons have been classified according to the depth of 
the structures which they attack. This woman states that she 
had an inflammation around the matrix of the nail, which is 
classified as the first variety of the affection. 

The disease commences under the cuticle near the root or side 
of the nail, the pus not being deep-seated is soon evacuated ; 
sometimes, however, the abscess takes place under the nail, in 
which case the pain is severe, and not unfrecruently shoots up as 
far as the external condyle of the humerus. 

The nail is sometimes punctured with a needle and the pus 
allowed to escape. In this case the pain is not very intense. In 
other varieties of felon, where the deeper tissues become affected — 
as the periosteum — it becomes very painful. In fact, I know of 
no more severe suffering than is found in the deep variety of felon. 
When they are in the palm of the hand the excruciating pain 
which the patient suffers is sometimes almost unbearable. In the 
earlier stages of felon it can sometimes be made to abort, that is, the 
inflammatory action may be subdued before suppuration is estab- 
lished. This may be accomplished by several means — one of these 
is the application of nitric acid; I have cured many in that way. 
Another by immersing the part in lye; another by keeping the 
finger in hot water ; and still another to wrap around the finger 
the skin of a hard-boiled egg^ which is between the white of the 
egg and the inside of the shell. 

At first the patient will experience aggravation of the symptoms, 
but, if the application be allowed to remain, or perhaps applied at 
intervals, the affection will often be arrested. 



NECROSIS OF THE TIBIA. 65 

These means may be used provided it has not reached the third 
stage, or suppuration has not commenced. If suppuration has 
begun, then all of these applications are worse than useless. 
Again, if the inflammatory action has commenced under the 
periosteum, the pain is more intense. In such a case the incision 
must be made early ; but if it is above the periosteum, and espe- 
cially if it is in the palm of the hand, it is better to wait until the 
pus forms. In other cases the formation of pus is so slow, and the 
pain is so severe, that it is better to open down to the periosteum, 
and relieve the tension by allowing the exit of blood. This 
person has had, first, a simple " fester" on the end of her finger, 
and the inflammation from improper treatment extended up the 
arm, as you see in the red lines extending up the forearm. This 
is not exactly metastasis. 

We can have an extension of the inflammatory process by con- 
tiguity or by continuity. We know that there are certain organs 
in the body which, although at a remote distance, sympathize 
with each other. In such we have extension of disease by re- 
mote sympathy. We have also extension of inflammation by a 
continuous layer of tissue. 

There has been an inflammatory action in this finger, which has 
been, by the application of hot water, driven to the arm ; the in- 
flammation has taken a backward action by continuity of the 
tissues, and now you see it located in the long flexor of the 
thumb. I would advise the patient to localize the inflamma- 
tory action by means of a poultice. If the inflammation is con- 
fined to the finger it is all right, but if it extends up the arm it 
is all wrong. Give her arsenicum internally, the 30th, every four 
hours. Change the poultice once every three hours. Apply the 
poultice as hot as it can be borne and make it of ground flaxseed. 
Let the arm be supported, and I think that a cure will soon be 
effected. 



Operation by EsmarcKs Method. 



Emma Slack, Aged Ten Years. 
I have here an interesting case to show you ; and, before she is 
placed under the influence of the anaesthetic, I desire to say a few 
words to you about her. We have got through the inflammatory 

5 



66 NECROSIS OF THE TIBIA. 

process in our coarse of lectures, and also through some of the 
diseases which partake of the nature of inflammation. You will 
recollect that I told you that inflammatory action could extend 
in the bony system. We have periostitis, then osteitis, osteo- 
myelitis, caries and necrosis. Periostitis is not a disea.se of the 
bony structure itself, but of that strong fibrous covering which 
overlies the bone, and not only protects it but assists in its new 
formation. Then we have also an affection of the lining membrane 
of the medullary canal. A. step further we have caries of the 
bone, or ulceration ; and, finally, the complete death of the bone. 
The process bears the same relation to the bony structure that 
it does to the soft parts. In the soft parts we have dry and 
moist gangrene ; so in the bone we have the hard and the soft 
processes. 

History of Emma Slack's case, now before us. Her trouble 
began with a pain in her knee eight months ago. She had not 
injured it, so far as is known. She was treated for rheumatic 
fever, and was sick about four weeks. When she grew better there 
were some purple elevations on her leg. They swelled, and finally 
broke and discharged. Before they opened she had a great deal of 
pain. The pain was worse at night and better towards morning. 
During the first part of the night, and until three or four o'clock in 
the morning the suffering was very great. These ill-conditioned 
abscesses would break, then others would form, and, finally, two 
pieces of bone came out ; the largest was about two inches long 
and as broad as the finger. One side of the bone was smooth 
and the other w^as rough. She pulled the bones out herself. 

Prof. Helmuth. — Osteitis, or inflammation of the bone itself, gene- 
rally commences in the bone corpuscles, or in the calcified tissue 
which is around them. I have not time now to go into a de- 
scription of the cell formation of bone, and as you have already had 
that from two or three other members of the faculty, I hope you 
understand all about it. 

An acute attack of osteitis is a rare disease, but chronic osteitis, 
passing through all the different forms of caries or ulceration, is a 
very common affection. Of all the structures of the body the 
bones, as you are aware, are supplied with the smallest amount of 
blood vessels ; but the periosteum on the outside, and the medul- 
lary matter on the inside, and the membranes that line the medul- 
lary canal, are profusely supplied with blood. Therefore, although 



XECROSIS OF THE TIBIA. 67 

it is rare to have a primary inflammation going on in the substance 
of the bone itself, yet inflammation of the periosteum or medulla is 
not an uncommon affection. You will find that the medullary 
membrane is the first to be inflamed, and afterward the disease 
extends to the bone. Just exactly as I have tolcl you, the 
process goes on in the soft parts, so we have it in the bone. We 
have a molecular death, and a degeneration of the bony tissue : 
the molecules are carried off with the discbarge, constituting 
caries. As I have told you before, the appearance of a carious 
bone very much resembles a lump of hard sugar which has been 
dipped for a moment in water ; it is granulated, and these small 
granules seem to pass off with the discharge itself. Then we have 
the true death of the part or necrosis. Necrosis is the entire death 
of bone up to a certain part. The sequestrum is that portion of 
the dead bone which has to be separated from the living. A 
sequestrum is not always a loose portion of the bone. On the 
contrary, a portion of the sequestrum may die and yet be attached 
to the living bone, which is supplied with blood vessels up to the 
point where the sequestrum is attached to the bcny surface. Then 
again, a sequestrum may die; nature, in endeavoring to repair the 
parts, may form around the dead portion a shell of bone, which 
becomes harder and harder, and which is called the involucrum, 
■which encases the sequestrum. Through this the dead portions can 
be discovered by the probe, or through the cloacas. Sequestra are 
also sometimes cast off, the hue of which resembles that of ossific 
matter which has been for some time buried in the earth. When 
a sequestrum is discharged the disease may be considered at its 
height, for nature is throwing off the dead structure, which can 
no longer be of any service to the economy. Often at this period, 
by introducing a probe, several pieces of detached bone may be 
readily felt. 

This child has had some rheumatic affection or periostitis. 
Whether it resulted from an injury, or whether the child was 
scrofulous, I am unable to say. Certain it is that she had perios- 
titis, then caries, and then an entire death of some portion of the 
bone took place. She perhaps had acute caries. You know that 
in chronic necrosis a patient may get about for j T ears with one 
or two openings in the leg, and pieces of bone discharging ; 
but in acute necrosis the whole bone seems to be invaded, the 
inflammatory process spreads with rapidity, the entire structure, 



68 NECROSIS OF THE TIBIA. 

up as far as the joint (and very frequently the joint itself), is 
involved, and there is a contraction of the tendons, and a partial 
necrosis of the bones in the vicinity. 

What shall we do in this case? When I first saw her this 
morning I was disposed to recommend an immediate amputation 
of the leg above the knee, because I know that these prolonged 
operations on the bone are sometimes extremely serious ; often 
they do not effect a cure, and, sometimes, after the best directed 
efforts, amputation has finally to be resorted to. Upon conversing 
with the mother she expressed a most decided objection to the 
removal of this leg. To one who does not look upon these 
things as we do, and to a mother in particular, who regards the 
child with all the affection which we naturally expect, there is 
something so repellant in the idea of amputation that opposi- 
tion is natural. To say to a mother that such and such a part 
of her child must be removed — no matter how great has been the 
extent of the inflammation which has been going on — is a com- 
munication, so awful to her, that it staggers her. When I suggest- 
ed to this mother that an amputation might be necessary, she at 
once rebelled against it. Kemembering what can be done by the 
method of Esmarch, and how much better we can operate by his 
mode than we formerly could, when the blood would pour out 
over all the parts, I have concluded to perform Esmarch's opera- 
tion for the removal of necrosed bone, and remove as much of the 
disease as I can — all of it, if possible. If I find that I cannot re- 
move all of it, and that amputation is necessary, I will remove as 
much as I can, close up the wound, and wait until the father 
of the girl can be consulted. I do not want to take upon myself 
the responsibility, nor give the college the reputation, nor homoeo- 
pathy the discredit of operating helter skelter, without the consent 
of the parties interested in the case. And, besides, it would not 
be a proper or a right thing to do. I would not thank anybody, 
in my absence, to take off the leg of my child without previously 
consulting me, no matter how bad it was. Therefore, I give the 
same right to the father of this girl which I reserve to myself. He 
lives in Mystic, Conn. I hope it may not be necessary to remove 
the leg; but I am sure that extensive disease of the bone will be 
found, and I am also sure that the operation will be a prolonged and 
difficult one, because when you commence you must do it thor- 
oughly. I propose, after the bandage is applied, to make a long 



NECROSIS OF THE TIBIA. 69 

incision over the tibia, and see the extent of the disease, and how 
much can be removed. If it is caries, the bone may be scoped. 
If there is necrosis (and I think there is), I will remove as much 
of the dead bone as I can find. 

In the removal of diseased bone a great many instruments are 
required, particularly if the involucru n seems to close around the 
sequestrum ; because then it is not only necessary to use the tre- 
phine, but the hammer, chisel, saws and forceps as well. Here, 
for instance, are a pair of lion forceps of Fergusson. The fault 
with ordinary bone pliers is, that they do not have leverage 
enough when you want to divide a hard portion of bone. Here are 
chisels and retractors to hold back the skin, and " holding " forceps, 
to secure a piece of bone, while the saw is being used. 

I hope to be able to remove a portion of this bone with a single 
incision. "We will apply Esmarch's bandage over another band- 
age, to prevent it being soiled by the discharge. Then we will 
make a longitudinal incision, and see the extent of the disease, 
and afterwards pack the wound with tenax, or prepared tow. 
This prepared oakum or tenax is now specially prepared for surgi- 
cal dressing. Oakum, proper, is made from old tarred ropes. This 
substance is made from hemp, and the tar is afterwards put in 
especially for surgical dressing. It is much finer than oakum, and 
you get rid of the sticks and of the chunks of tar. Besides being 
a good disinfectant it is a good dressing for the leg. There is 
another article, made of fine hemp, which keeps much more moist, 
and has a softer feel. It is also much more impregnated with 
creosote, and is, therefore, a better disinfectant. 

In the absence of this prepared tow you may pack the wound 
with lint, or you may employ cotton. But cotton is not so good 
as lint, because it is too shreddy, and sometimes sticks, and is 
difficult to get out. I heard recently quite, an argument as to the 
propriety of using cotton as a surgical dressing. Cotton has been 
very highly recommended by several eminent surgeons; but there 
are other material that are a great deal better. If, however, you 
could not obtain other material, it would be proper to use cotton. 
In certain forms of suppurating diseases cotton seems to have a 
certain power over abrasions of the surface. By applying it to 
a burn you relieve the pain very much indeed, not only because 
of the exclusion of the air from the raw surf ice, but because there 
seems to be some property in the cotton applicable to the injury. 



70 OPERATION FOR NECROSIS. 

[The patient was brought in, etherized, on a stretcher.] 

We put on this cotton bandage to prevent soiling the elastic 
one. Speaking in a general way, there are no operations 
more unsatisfactory than those on the bones ; but Es march has 
done a good deal towards simplifying them. One of the disad- 
vantages claimed for Esmarch's operation is this, that in wounds 
where there is a great deal of suppuration, and where there has 
been a profuse discharge of pus, there is danger of forcing the 
pus into the circulation. Another of the dangers which is charged 
against it is the oozing from the flaps, which is said to follow. 
The blood is withheld from the capillaries so long, that when the 
bandage is removed they do not contract, and injury to the 
flaps results. Now that the bandage has been applied you see 
that the leg resembles that of a dead person. 

I make the first incision — putting the knife in at the tub- 
ercle of the tibia and bringing it down to an inch above the 
ankle. You see that no blood flows. There would be very incon- 
venient bleeding were it not for this bandage, because the tissues 
are all congested, and the cavities are full of blood. As it is, there 
is no special hurry ; I cut through the tissues and down to the bone. 
I remove some of this slough with a sponge, and I see quite a large 
sequestrum. Now I will take a pair of forceps and see what I can 
do with it. (Eemoves bone, scrapes it.) Thisis the piece of bone 
that has caused the most of the trouble. The sequestrum is sur- 
rounded by an involucrum. Now I shall scrape the bone. The 
discharge is very foetid and offensive. 

There (demonstrating) is the new bone which has been forming 
around the old. I can feel it very distinctly. I will take a probe 
and put it down through the cloacae. In this other opening I 
find that the bone has entirely degenerated and softened, and I 
shall therefore scrape off as much of it as possible. The little 
blood that you see oozing comes from the medullary cavity. As 
soon as the bandage is loosened you will see the blood rush into 
the leg like a sponge, and then we shall have a smart hemorrhage 
for awhile. 

If this were my patient, and I had the consent of the father and 
mother, I should remove this leg at once. I find that the probe 
goes directly into the cavity of the knee joint ; but having given 
my word not to perform amputation to-day, I will do the next 
best thing I can. Here is another piece of loose bone, which I 



OPERATION FOR NECROSIS. 71 

will cut out by using the chisel. There is not much chance 
that this operation will be successful ; but I will nevertheless try 
to save the girl's leg. This disease began in the membrane which 
lines the medullary canal and extended outward. The bone is 
not so much necrosed as you would expect to find, but it is soft- 
ened, degenerated and ulcerated. You know that an ulceration 
is a degenerated condition of the bone — a softening and breaking 
down of the structure. 

I will now pack the wound with tenax, bring the lips together 
as best I can, and await the result. 

I am very glad to show you the operation of Esmarch. It has 
been a perfect success so far as the operation goes. I think it is 
especially fitted for the removal of the necrosed bone. In such an 
operation as this, even with a tourniquet applied, we would have 
had hemorrhage which would have discommoded us greatly. 

The next point is to wash the wound thoroughly by introducing 
the nozzle of a syringe into the opening. 

This patient has been under treatment about five months, and I 
suppose has taken all the ordinary homoeopathic remedies. I shall 
put her on silicea immediately. That is my great remedy, and it 
has done more for me in cases of this kind than any other medi- 
cine I have ever used. 

In packing any cavity it is well to recollect one thing — that it is 
better to have the substance 3^ou wish to pack with in one con- 
tinuous piece, or else know just how many pieces are used ; because 
sometimes it is very difficult to remove them, and if }'ou leave one, 
disastrous results will follow. I was once called to operate for a 
case of necrosis at the lower end of the femur, and I found a piece 
of sponge that had been there for five years. It was about as big 
as the end of my finger. The wound had healed, but this sponge, 
acting as a foreign substance, had caused further irritation, which 
gave rise to disease after the necrosed portion of the bone had been 
removed. 

I want you to observe the condition of the parts after the blood 
is let into them. As the circulation is established again, and the 
veins fill up, it begins to bleed. We expect that there will be a 
considerable quantity of oozing from this wound. 

The question of amputation is one of the most serious that a 
surgeon has to entertain. Whether you shall or shall not remove 
a portion of the body is a question demanding a great deal of 



72 CICATRIX. 

serious consideration and a great deal of actual experience. When 
this question relates to the saving of a limb, we are to inquire 
whether the leg, if saved, will be a serviceable one or not. It is 
better to get rid of a leg sometimes than save it, if the leg is to be 
of no service, in the way, and a deformity. If, however, j^ou think 
that you can preserve a limb and make a useful member of it — 
enabling the patient to use it in a measure — then, of course, it is 
better so to do. But I am of opinion that, in a great many in- 
stances, conservative surgery saves legs, arms, and fingers that are 
deformities, and are only in the way. In the present advanced 
state of mechanical surgery it is better to remove the member 
than leave a deformity. You can have a patent arm so perfectly 
constructed that a man can drive horses or eat with it. I have seen 
patent legs so well adapted to their place that, if it were not for 
the manner in which the boot fitted, }< ou could scarcely detect they 
were artificial. It is better to have an artificial leg, with which 
you can move about with comfort to yourself and everybody else, 
than have an unsightly limb which is always in the way. 



Susan Chrixe, Aged Seven Years. 

( Con tinned from page 25. ) 

This girl was here four weeks ago. The sore has suppurated 
and discharged since then. This was one of the tendencies to sub- 
cutaneous ulceration for which we ordered silicea. She is now a 
great deal better in every way. Let her return in three weeks and 
I think she will be cured. 



Stmtfal mmt at §mmhtx mt> IBM, 



8<*tt**+mai4'* Ra**< 



Mary McMullen, Aged Sixty Years. 

(The patient says she has a soreness and swelling below the 
knee ; don't know that she has strained the leg.) 

Prof. Helmuth. — Bursas sometimes enlarge and inflame and oc- 
casion great suffering. We frequently see them about the wrist 
joint and on the dorsal tendons of the hand. When an adven- 
titious bursa is formed along the course of a tendon the term 
ganglion is generally employed — and I do not know of any more 
difficult disorder to treat than the diffuse variety of bursas. So 
long as we have the synovial fluid contained in the sac, and there 
is but slight inflammation, there is merely an unpleasant feeling 
when the tendons or muscles play over the cyst ; but in other 
instances the contents of the sac increase in quantity and the fluid 
burrows down into the sheaths of tendons, and causes a great deal 
of inflammation and suppuration, sometimes resulting in gangrene 
and death. A bad case of eranelion is a most difficult thins: to 
manage ; but the ordinary bursas are not so troublesome. There are 
a great many ways of managing them. Recollect the distinction : 
First, you have the simple bursa, in its natural position ; then you 
have an enlargement of the bursa, which rises on one side of 
a tendon or the other ; and third, we have the diffuse bursa, in 
which the fluid extends along the tendons, and gives rise not only 
to excruciating agon}', but sometimes to the death of the part. A 
bursa in this place is frequent with women who do housework. 
Eesting on the knees for a considerable time appears to irritate the 
parts, and the cyst begins to inflame. A very simple treatment 
is to pass a seton through the sac and let it remain until a 
certain amount of irritation has set in. Dr. Thompson suggests 
stica pulmo. I have never used it, but will try it in the next 
case -we have. (The seton was then passed.) 



Henry Nichol, Aged Sixty-two Years. 

Prof. Helmuth. — This patient states that, up to this morning, he 
had not been able to get a drop of water down his throat for 
forty-eight hours. He has been afflicted since the first week in 
July last. He is a journeyman tailor by occupation. Up to the 
present he has always enjoyed good health. He used to carry his 
lunch to the shop, and about the first of July experienced difficulty 
in swallowing it. He could swallow liquids better than solids. He 
has fed on soups and broths, and has eaten no solid food since July. 
The food does not immediately regurgitate, but after he has eaten 
a little, the throat seems to contract, and whatever he happens 
to have in his mouth at the time he cannot swallow, and he 
has to eject it. For the last forty-eight hours the throat has been 
closed. 

Those of you who have entered into the anatomy of the oeso- 
phagus know that outside the mucous coat of the tube we have a 
certain variety of muscle. When I was speaking to you at a 
former clinic, with reference to the action of the muscles which 
enter into the formation of the pharynx, I told you that the 
tendency of these muscular fibres was to contract towards the 
centre, and that this motion occasions that peculiarity of cleft 
palate which enables a person so afflicted, in swallowing, to bring 
the edges of the cleft together, when we would expect that the 
gap would be widened. The same condition of the muscular 
fibres extends down the oesophagus. 

We have here a case of stricture of the oesophagus. You can 
divide this into two varieties. First, the spasmodic stricture ; 
and, secondly, the permanent organic stricture — the latter em- 
bracing the chronic induration and the malignant variety. 

In spasmodic stricture the circular muscular fibres are the seat 
of the affection; the disease occurs at intervals, the patient sud- 
denly finding himself incapable of swallowing, at the same time 
experiencing a sensation of choking ; added to this, there is not 
much emaciation, although there is generally great nervous irrita- 
bility of the whole system. The disease is more prevalent among 
females than males, and is amenable to internal medicines. 

One of the most interesting cases of this kind has been published 



STRICTURE OF THE (ESOPHAGUS. 75 

in the North American Journal of Homoeopathy, from the pen of B. 
F. Joslin, Jr., of New York. The patient suffered extremely, 
and, notwithstanding the best directed efforts, finally succumbed 
to the disorder. The post mortem examination revealed a small, 
hard, osseous tumor, an inch long and half an inch in breadth, 
with various spiculae of bone projecting from it, situated just 
above the bifurcation of the trachea ; a nerve was found very in- 
timately connected with the anterior face of this tumor. Dr. Joslin 
considers this filament to have been a cardiac branch of the 
pneumogastric nerve, the irritation of which, by the presence of 
the tumor, caused the difficulty in swallowing. The writer says 
the bony tumor " did not press on the oesophagus, and was only 
loosely attached to the trachea; it was firmly adherent to the pos- 
terior portion of the vena cava superior ; it could only be impli- 
cated in the production of the symptoms by its relations with the 
pneumogastric nerve." 

In the one form — of organic structure — we have a vari ty of 
thickening almost similar to that which we have in organic stric- 
ture of the urethra; there is a deposit of plastic material which 
is thrown out around the interior of the oesophagus. 

Among the symptoms of this variety of stricture we see, first, 
the tendency to regurgitation of food ; occasionally the spasm 
seems to close up the opening for a considerable time ; and the 
effort to swallow any cold drinks creates a tendency to shut 
the oesophagus. In organic structure there is complete obstruc- 
tion and always accompanying indigestion ; you will also notice 
a peculiar expression of the face, the features being pointed and 
exhibiting the tokens of anguish and distress. You see, also, that 
the patient is considerably emaciated, and that not only the 
nerves that supply the oesophagus but also the inferior laryngeal 
nerve is affected. (A sound was then passed down to the stric- 
ture.) • 

What is best to be done in such a case as this? Some have 
been radically cured of spasmodic stricture of the oesophagus by 
properly administered homoeopathic medicine. 

The patent states that the throat contracts very suddenly on 
attempting to eat. Sometimes half a wine-glass of food will 
be swallowed and stay for some time, and then it is thrown off. 
It arrives at the constricted portion of the oesophagus and there 
it remains until further constriction throws it up. 



76 CONGENITAL HERNIA. 

The first direction I give this patient is never to take anything 
cold — not even cold drinks. He should take liquid nourishment, 
and take it warm. And I would recommend that, before he begins 
to take food of any kind, he should envelop his throat in a hot 
bandage. Tie around his throat, before he attempts to eat, a 
piece of towel, or muslin, or canton flannel, which has been 
dipped in very hot water, and over that apply a dry bandage. These 
spasmodic strictures will sometimes relax under the influence of 
heat, I will give him the 30th of cocculus — a dose every three 
hours. 

In these cases of stricture of the oesophagus the patient some- 
times dies from lack of nutrition. 



Abraham Jones, About Fifty Years. 

History of Case. — (Has had hernia ever since he was a boy. Don't 
know what caused it. Has tried a number of trusses, but derived 
no benefit from any of them. Has employed several doctors, but 
none of them did him any good. Has no pain from it.) 

Prof Helmuth. — There are several varieties of hernia — the re- 
ducible ; the irreducible, in which coats of the sac are adherent to 
the surrounding tissues by fibrous deposits; then, again, we have 
incarcerated hernia, and we have strangulated hernia. We have 
also a division into the congenital and the acquired variety. 
Again, we have different varieties of hernia, according to the 
locality and the nature of the parts protruded, all of which are 
important to be known. 

This man has congenital hernia. The method of reducing her- 
nia by the hand is called taxis. There are a great many methods 
of performing it. This is an oblique hernia. By that I mean a 
hernia which passes through both rings. The gut passes down in 
front of the sheath of the conjoined tendon of the transversalis 
and internal oblique muscle and descends into the scrotum. One 
portion of it feels " doughy " and the other feels as an intestine 
should, making it an entero-epiplocele. 

In replacing the hernia you can always tell when it passes back, 
for it slips away from the fingers with a gurgle. There should 



FISTULA IX AXO. ARTERITIS. 77 

never be any force applied in replacing a gut. A patient with a 
hernia can generally put it back himself, and do it even more satis* 
factorily than can a physician. This hernia is so old that the 
rings are very near together ; and, although you can replace it, as 
you see, it slips from under the fingers. (A proper truss was or- 
dered.) 



^"i^^J^ in &np 



Abraham Baker, Aged Fifty Years. 

This man has what is called blind fistula — blind external fistula. 
By that I mean to say that he has a fistula which opens exter- 
nally and is blind internally. The terms " externally blind " and 
li internally blind " often give rise to a great deal of discrepancy 
of description. It is better to say that this is a fistula which is 
blind internally. It opens on the outside and not within the gut. 

There are cases upon record which have been cured by the inter- 
nal administration of medicine, but I have never \^et seen such, 
although I have endeavored to cure them by such means. 

My advice to this patient is to get on his knees and let me cut 
it right out for him. (The patient decidedly objected.) 

There is another way of getting rid of it — that is to introduce a 
ligature, tie it over a small pad, let the strings hang down, then 
tighten the knot from day to day. 

But the best plan is first to make this a complete fistula, cut it 
directly through, and allow it to heal from within. 



&¥t$¥iHm* 



Lewis Huttwohl, Aged Forty Years. 

There are certain diseases of the arteries which are obscure ; 
but there is one in particular which is caused by an irritation of the 
vessel. It comes under the head of aneurismal diathesis, but 
it seems to be a disease which affects the elastic coat of the 
tubes, and is generally preceded by some affection of the heart. 



78 ARTERITIS. 

Whether this belongs to that class or not it is impossible for me 
to say on such an examination as I am now able to make ; but 
there seems to be a diseased action going on in the whole arterial 
system. When I apply my ear to his breast I hear that there 
is much regurgitation of blood. There is a blowing sound, show- 
ing that there is valvular irsufficiency. He has a thickening of 
the pericardium and an affection of the arterial system. Al- 
together it is a case of very rare interest. 

I should suppose that some of the preparations of ergotin would 
be advisable in this case ; but as he has already been before two 
of the other professors, I have nothing to say as to the treatment, 
but will consult with them in the case. 

Never be too certain in your diagnosis, when another physician 
has been before you, in an obscure case. If you desire to keep 
yourselves out of trouble in such cases, particularly when they 
have been prescribed for by other medical men, be sure that you 
call a consultation before you give a definite opinion. You 
do not know what damage you may do to yourselves, or to 
your profession, by expressing an opinion which may be directly 
at variance with that which has been already given by an-, 
other. As doctors differ so materially in their opinions of 
most cases, it is always well, if you are called upon by a 
patient who has been visited by another physician and asked, 
"What do you think of my case?" to say, " I will see your medical 
man about it." Never express your opinion, after a consultation, 
to the patient, but always to the doctor in attendance. Never, under 
any circumstance, give an opinion of a case that is in the hands of 
a brother physician, but always let him perform that duty. When 
you are called in consultation you must take your leave of the 
patient before the consultation is held, and not return. The family 
physician is to receive and express your opinion, and prescribe for 
the patient. That is the rule, and the correct one. This running 
up stairs again to see the patient, and saying to him, "If I had 
been here day before yesterday you would have been all right," 
is very reprehensible, although the practice is prevalent among 
some of the profession ; but they always come out at the small 
end of the horn. You cannot be too careful in your ethics. 



John Hart, J.(/ec? Twenty -nine Years. 

History of Case. — (The patient says when he was about two years 
old he took a large dose of arsenic by accident. At the age of five 
had hip disease, and suffered a great deal of pain. Then two abscesses 
formed, discharged and healed. At the age of fourteen the ab- 
scesses broke out in his leg again. He received an injury, when thir- 
teen, while splitting wood. The sore leg is now six inches shorter 
than the other ; he then got the foot fast between two sticks, and 
on turning around felt something snap in his hip, after which there 
was a large swelling inside of the thigh ; then two abscesses 
formed — one above and one below the swelling, 'then several 
places opened and healed — one sore after another — from that time 
to this. Has had no splints on the leg. Has taken only con- 
stitutional remedies, such as iodine and iron. Was in Bellevue 
Hospital for three months, under Dr. Hamilton, who used sponge 
tents, which gave relief for a time, so that he was able to go back to 
his work — that of compositor. Worked at the case until last July. 
No spiculae of bone have been discharged.) 

Prof. Helmuth. — That fact makes me think that there is more 
caries than necrosis, or if the latter, the sequestrum is not de- 
tached. 

Yon notice that the patient dresses the sores with paper. Paper 
has been largely introduced into certain hospitals as a dressing. 
It is not only very serviceable but it is cheap, and so easily ap- 
plied that it has superseded many other dressings. 

You see there are fourteen or fifteen openings on the buttock 
and thigh, and he has had as many as twenty-six. You see, also, 
that there are cicatrices all along the side of the hip. 

The diseased leg is now about six inches shorter than the other. 

This case is one of great interest. In the first place it shows 
what the human frame can suffer. When you look at that leg and 
see its attenuation, and remember the amount of pus that discharges 
from that poor fellow's thigh every day, you cannot but wonder at 
his power of endurance. He enjoys comparatively good health, 
his appetite is good, and his pulse regular. He has symptoms 
now coming up which resemble dropsy. This is the second 
or third case of hip disease we have had under treatment, and you 



80 HIP JOINT DISEASE. 

will recollect what I told you of the different varieties of the 
complaint. In such a case as this we have, I suppose, not only an 
ulceration of the head of the thigh bone but caries, with perfora- 
tion of the acstabulum. 

You see here two openings on the anterior portion of the ab- 
domen. When, in advanced hip disease, we have these openings 
for the exit of matter on the anterior portion of the abdomen, 
the indications are, that there is some more extensive disease 
than that of the thigh bone itself. This affection has lasted for 
such a length of time that there can be no doubt about the head of 
the bone being very seriously affected, together with the ilium. 

[The doctor refuses the request of the patient to stay in the 
room and hear all that is said about his case.] 

It is not to be wondered at that this man wants to hear every- 
thing that is to be said about his case. He wants to know whether 
there is the slightest hope for him. He desires to know whether 
he will live or die. He wants to know whether an operation 
can be performed for his relief. Under the circumstances I do not 
think that there can be. I fear that there is very little chance for 
his life in this world, but we may be able to somewhat benefit him. 
An exploratory operation in such a case as this might be advisable 
under certain circumstances ; but not when the patient has run 
down so low that there is effusion taking place in the abdominal 
cavity, because in such the operation would not be successful, 
and would but add to his suffering. It seems to me, if anything 
can be done for him, it must be treatment which will build him up. 
If necessary, he may be relieved of the dropsy, and then, if the 
water does not reaccumulate, you may cut down to the head of 
the femur and perhaps exsect it. In his present condition, how- 
ever, any such operation is out of the question. 



Jftwgic&t (&Vaat of Qovmlm BStfo, l&M. 



Elizabeth Fitzgibbons, Aged Thirty -eight Years. 

(A bad foot ; married ; has Lad nine children ; youngest six 
years old.) 

Prof. Helmuth. — Here is a condition of the leg occasioned by an 
obstruction of the venous circulation. It is occasioned bj 7 conges- 
tion, probably of some portion of the liver, which obstructs the 
return of blood, thus the veins become varicose. Whenever 
there is an inequality between the arterial and the venous supply, 
whether in the leg or in the heart, or in any portion of the body, 
then the tissues suffer. In this case ulceration will probably take 
place. The parts are now in a state of congestion, and are just ap- 
proaching an inflammatory stage — a sub-acute inflammatory con- 
dition — which will result in ulceration, and then she will have reg- 
ular varicose ulcers. 

A VARICOSE ULCER 

is a variety of indolent ulcer which precedes or follows a varicose en- 
largement of the veins of the leg or thigh ; it generally makes its ap- 
pearance on the inner side of the leg, and is often very difficult to 
cure. It resembles an indolent ulcer in a somewhat advanced stage, 
the edges of the skin, however, bounding the sore are not tumid ; 
the part is blue or purple ; the sore is seldom deep, usually spreads 
along the surface, and is oval in shape. The branches and trunk 
of the vena saphemi are enlarged, and this varicose state prevents 
the ulcer from healing. A varicose limb becomes very much 
swollen, the coats of the veins are often thickened, the vital power 
is much impaired, the temperature is diminished, the parts assume 
that dark blue appearance to which we have already alluded, and 
are excessively prone to the inflammatory process, ending in ulcer- 
ation, which is generally of a tedious character, although we find 
that the irritable sore is often accompanied with varicose veins. 
The pain appears to be deep seated, and extends up along the 
course of the vessels, and is increased by maintaining the limb in 
the erect posture. 

6 



82 TREATMENT OF INDOLENT ULCER. 

Treatment — In the treatment of indolent ulcers it is necessary 
that the utmost cleanliness be observed ; and if the patient be one 
whose constitution has been impaired by unwholesome diet, ex- 
posure lo a foul atmosphere, or by intemperance, these obstacles 
should be overcome by the substitution of nutritious, easily di- 
gested food, proper ventilation, regularity of habits ; in fact, as far 
as possible, every effort should be made to effect the removal of the 
predisposing cause. 

The indolent sore is capable of cure under homoeopathic treat- 
ment — indeed, in some instances, without having recourse either to 
the bandage, straps or escharotics ; and it is not absolutely neces- 
sary that the patient be put to bed, although over-exertion tends 
to retard recovery. 

It is impossible to cure varicose ulceration without doing some- 
thing for the cause of the disorder. Varicose veins may be oblit- 
erated in many ways. U nfortunately, the persons afflicted with 
varicose veins are usually those who have to stand on their feet a 
great deal. If this woman could rest for awhile, the best way 
to treat her would be to take two hare lip pins, pass them 
just underneath the vein and bring them out on the other side of 
the skin, about an inch apart ; then twist a figure of 8 suture over 
each of the pins and introduce between them a tenotome flat- 
wise on the finger, under the vein, turn up the edge and cut 
through the vessel. That is the best way if a patient can rest. 
By this method you prevent the entrance of air into the vein as 
well as hemorrhage. But there are some people who object to 
operations on varicose veins, and dislike to have pins and needles 
thrust into them ; especially is this so in women. " Do you find this 
so ?" " Yes, sir." You very often find a varicose condition of 
the veins in women before confinement, because the blood is ob- 
structed in its return by the pressure of the foetus, and the veins 
either give way or their coats dilate, and thus form varicose veins. 
There are also other means of obliterating varicose veins. An 
excellent method is the application of a paste composed of equal 
parts of quick lime and caustic potash, ground together, and kept 
in a glass stopped bottle in your office, and moistened, when you 
wish to apply it, with a little alcohol. This may be put on with 
a glass rod once a week until a sufficient inflammation is set up to 
obliterate the vein. It is a very convenient and effectual applica- 
tion. Many is the vein that I have obliterated in that manner 



CHEILOPLASTY. 



83 



while treating varicose ulcers, and allowed the patient to go about 
his business. After allowing the escharotic to remain a few mo- 
ments wash the parts with vinegar, put on an elastic stocking and 
let the patient go. Eepeat this every three or four days. Don't 
let the paste stay on long enough to burn through the vein. I once 
applied it to a patient at a clinic and forgot it while lecturing, and 
hemorrhage was the result. There are some medicines, which, 
if internally administered, will have a specific action on the coats 
of the vein, and the best that I know of is the Witch Hazel. 



Cfe^ll^l^S^ 



Miss T ■, Aged about Twenty -three. 

This young woman was before the class two years ago. I have 
performed four or five operations for her. She came to us first 
with a perfect immobility of the lower jaw. During the five or 
seven years that her jaws had been closed she was not able to 
swallow anything but soup, which she took through a straw or a 
glass tube. Several of her teeth ulcerated and she swallowed 
them ; she could not spit them out. Then it was that she came 

to us with this cicatrix — perfect an- 
chylosis of the inferior maxillary, an 
eversion of the lower lip, and a dread- 
ful cicatrix from previous ulceration, 
which probably arose from the inju- 
dicious use of mercury. Fig. 1 shows 
somewhat the condition of the parts. 
The first operation, which was prolong- 
ed, tedious and bloody, was to open 
the jaws. Introducing a round pointed 
straight bistoury at the inner angle of 
the mouth, I divided, after a tedious 
dissection, all the cicatrices ; then, 
with a modification of the instrument 
of Scultetus, called Westmoreland's, I gradually broke up the ad- 
hesions within the joint, and restored partially its movements. She 
was then placed in bed, and a gutta percha plate introduced into 
the mouth, between the raw surface of the cheek and the jaw, and 




Fig. 1. 



84 



CHEILOPLASTY. 




Fisc. 2. 



hickory wedges were kept between the teeth, to prevent the great 
tendency to contraction which is always to be expected in these 

cases. After three months I performed 
a second operation, which was as fol- 
lows : First having ascertained the 
size of the flap, I marked its contour 
in the cheek. (See dotted line in fig. 
2.) Then without hesitation I cut 
cleanly out all the cicatrical tissue. 
The flap was then dissected up — 
"jumped, 1 ' as it is called — in other 
words, twisted on its pedicle, and 
sewed in place. This was very satis- 
factory {vide fig. 2). The third opera- 
tion was performed about a year after- 
vvard, and consisted of cutting a lu- 
nated strip of mucous membrane and muscular fibre from the 
lower lip and bringing the edges of the wound together; then 

cutting a triangular portion from the 
angle of the lip, to restore as much 
as possible the contour of the mouth. 
Fig. 3 shows the result of the opera- 
tion. 

She now comes to us again with the 
cicatrix somewhat contracted and the 
parts grown down. I want to depress 
the angle of her mouth, and the first 
thing to be done is to dissect up these 
adhesions which have grown from the 
flap taken from the side of her face. 
The first thing to be done is to dis- 
sect up this from the mouth. I 
have used a great many substances between the jaw and the cheek 
in these different operations. The gutta percha did not answer; 
then I tried parchment ; that did not do. I have brought here 
to-day some silver foil, which I shall endeavor to slip in after Dr. 
Thompson has dissected this flap up. The trouble with all these 
operations about the jaws is the formation of what is called modular 
tissue, and the tendency of this tissue to reiurn. I cut the whole 
of that out in the former operation, and the success was quite re- 




Fig. 



HIP JOINT DISEASE. 85 

markable. The instrument used in this case to hold the jaws 
apart was Westmoreland's. 

Plastic operations are those by which raw surfaces are brought 
together. The simplest form are operations for hare lip. In all 
procedures of this kind the object is to so unite the flap as to 
allow the circulation to proceed undisturbed. This girl has been 
very courageous ; she has suffered many operations ; and I hope 
that this will be the last one. I have had photographs of her 
taken at different stages of the cure.* I will bring -them to the 
clinic and let you see the changes. I am very anxious to make it 
a success. 

A surgeon must have eyes in the ends of his fingers. No other 
profession requires so much dexterity with the ends of the digits. 
A surgeon needs to educate not only the eye but the hand as well. 
A very good method of educating the fingers, and to improve the 
sense of touch, is to wind your watch every night in the dark — 
finding the key hole with your finger. 



Slip $$im>i JDiaea*** 

August Sissman, Aged Twelve Years. 

(Continued from page 60.) 

You will recollect that in speaking of this case, three weeks ago, 
I told you that in a majority of cases of hip disease you could trace 
the disease back to some injury. Formerly hip joint disease 
was characterized as a scrofulous affection of the joint; but more 
recent investigations have convinced us that in very many cases 
it can be attributed to injury; and we often find that healthy 
persons are afflicted with hip disease. You recollect the appear- 
ance of this boy when he first came here, and can see that he 
is in every way improved. I then prescribed silicea, 30th, and 
said that it was better that he should have an extension appa- 
ratus made, and that such apparatus would be required before he 
could be perfectly cured. The extension apparatus is made and he 
is to have it to day. The whole aspect of the patient has improved 
in three weeks. You will notice that the tendency of his foot is now 
to invert. In its earliest stages this disease is often very difficult 

* The wood cuts are accurate representations of the photographs. It will be seen 
that in the cuts the deformity is on the left side in Fig. 1, and shown on the right 
side in Figs. 2 and 3. The reason will be apparent when the fact is known that the 
photograph of Fig. 1 was taken from a photograph, while those of Figs. 2 and 3 were 
taken from the patient herself. 



86 HIP JOINT DISEASE. 

to determine. Perhaps after a run, or a jump, a strain or a fall, 
a child that has been active will complain in the morning (if 
stiffness in the hip — a stiffness of so slight duration, and so 
slight in itself, that the parents will let it pass unnoticed ; or, 
v,s the day wears on, the pain and stiffness will disappear, and the 
child will not feel the irritation unless it is quiet for an hour or 
two. The irritation may continue, arid the pains increase until 
they become agonizing, especially at night ; the leg will then 
become apparently lengthened, and rotated outward. The rotation 
outward is caused by effusion into the cavity of the joint. You can see 
this effect illustrated by injecting into the capsule a certain amount 
of quicksilver ; you will find that when the joint becomes full 
the foot will turn outward. It is at this stage of the disease that 
it is so particularly trying. It is at the second stage of hip diserse 
that the patient frequently suffers the most excruciating pains. It 
is because of the strain on the fibrous capsule that envelopes the 
head of the femur. This joint being full of fluid, the internal ro- 
tator muscles cannot act, and the external rotator muscles turn the 
thigh outward. 

(Another patient is brought in with the same disease.) 



-*-*-► 



George Lee, Aged Eight Years. 

Here you have the two stages of hip disease. As the disease 
progresses abscesses form around the joint and discharge in differ- 
ent parts of the thigh, either in the immediate vicinity of the joint, 
or burrow between the muscles and find exit behind. As the dis- 
ease progresses further the head of the bone becomes carious, and 
sometimes, but very rarely, dislocates. It used to be considered, as 
one of the peculiarities of hip disease, that the thigh became dislo- 
cated ; but this did not take pluce nearly so often as was supposed ; 
more frequently the acetabulum gives way, or the head of the 
bone is pushed through the acetabulum. 

Here you see two cases of hip disease in their advanced stages. 
One has been existing much longer than the other. The amount of 
suppuration taking place in the elder o*:e is perfectly miraculous, 
and still more miraculous is the manner in which his system stands 
it. He has very much improved within the last week or ten days. 



COLD ABSCESS. 87 

He feels better and stronger in every way. This bcyy goes to-day 
to the instrument maker to have the splint applied, which will allow 
of a certain amount of extension. There has been a great deal of 
improvement in both of these cases, and I hope to be able to 
bring them before you from time to time during the winter : if 
it is advisable we will make an exploratory operation upon the 
elder. He wants to see what can be done, and that is just what 
we all want. He has had a great deal of suffering. When you 
find abscesses in hip disease opening through the abdominal walls, it 
is not a favorable symptom as a general thing, because it shows 
that the floor of the acetabulum has been perforated, and the head 
of the bone must be thoroughly diseased. In such case excision of 
the hip cannot be performed with, the same facility or success as if 
the bone still remained in the cavitv. 



0ol4 A1>*e*j»j»: 



Harriet Crossley, Aged Twelve Years. 

(Enlargement on the side of neck ; has been sick over a year; the 
first symptoms were a swelling of the neck, which extended to the 
breast.) 

Prof. Helmuth. — There is a gland which is caUed the parotid, 
beginning at the angle of the jaw and extending upward to the 
ear. This gland frequently becomes enlarged, and indurated, and 
then gives rise to a great deal of trouble. In other instances, where 
the cervical glands become enlarged they suppurate, and form cold 
abscesses. I mean by that, the suppuration which takes place is 
extremely slow, is unaccompanied by constitutional symptoms, and 
generally discharges some distance from the point where the inflam- 
mation commences. You will see that this is quite an interest- 
ing case. The inflammatory process began at the root of the neck, 
and you can see how the matter has burrowed and opened lower 
down. On her back she has another abscess forming, which con- 
tains fluid. I think that we can cure this girl, but it will take a 
good deal of time. Give her Hepar — -the third — about two 
grains to be put in half a glass of water, and a sp>onful taken 
four times every day for three or four weeks. There is no medi- 
cine that I know of that possesses such influence over the sup- 
purating processes as Hepar, particularly when the glands are in- 



88 TREATMENT OF COLD ABSCESS. 

volved, and there is a tendency to suppuration in different parts of 
the body. By giving this medicine regularly, and following it up 
with silicea and sulphur, the disease may be radically cured. In 
cases like this I want you to bear in mind the importance of con- 
stitutional medication ; I do not mean constitutional general treat- 
ment, as implied bj r ordering iron, quinine, lime and stimulants. 
I mean that specific constitutional medication that applies itself to 
the specific condition of the disease. Study out the symptoms 
and give the appropriate constitutional medicine, and you will 
cure your patient. The tendency in these diseases which we 
see with our eyes, and which are appreciable to our senses, is 
to rely too much upon local treatment. Local treatment is all very 
well ; but I tell you, from actual personal experience, that these 
affections can be and are radically cured with very little local treat- 
ment, if you can select the right constitutional medicine — which 
is indicated by the symptoms of each particular case. The more 
you particularize, the more you scrutinize each particular case, and 
study the symptons of that case, and apply the medicines specifi- 
cally, the more speedily you will cure your patient. To be sure 
this is not an easy matter. It is a great deal easier to say that you 
will "build the patient up," by giving him tonics; but that is not 
the best ivay. You must study the symptoms of each particular case. 
It will weary you, and discourage you very many times ; there will 
be many drawbacks ; but the man who carefully studies the 
symptoms of each particular case, and applies the medicine accord- 
ing to the proper law of cure, he is the man who cures his patient ; 
and he is the man who can best instruct others in the law of cure 
which we profess, and believe, and know to be true. There is no 
denying this law of cure, because it has been tried. It has been 
put into the furnace and has come out pure gold. I believe 
that by the proper application of medicines according to our 
law, especially in bone diseases and this form of suppuration, 
can be effected in a majority of cases without the use of the 
knife. This may be bad for the surgeons, but we must be men 
enough to acknowledge the law and the facts as we find them. 
Don't be afraid to acknowledge a fact when you see it. It is all 
very well to sit clown and say, "This is not so ;" but the straight- 
forward conscientious man will never be afraid to acknowledge 
the truth wherever he sees it, and no matter by whom pronounced. 
That is the principle upon which I want you. all to act. Acknowl- 



HYPOCHONDRIASIS. 89 

edge the truth wherever you find it, no matter whether it be in 
this or in that college ; no matter what profession, school or church, 
uphold it. Whenever you are convinced of a truth, and have the 
facts to back it up, then let the world storm as it likes ; you have 
the truth on your side, and — " Magna est Veritas" 



S. 



Michael M., Aged Fifty Years. 

Has a "tickling noise in his head," and his "chest feels bad;" 
has no cough ; no pain any where in particular, except sometimes 
in his head ; sleeps well at night. 

[The patient insisted on entirely undressing before answering 
any questions, saying that he wanted to have a " regular examina- 
tion."] 

Prof. Helmuth. — The diagnosis in this case is quite clear. He 
says that his appetite is good ; that he sleeps well. His pulse is 
at 96. He is scarred all over with the marks of syphilitic erup- 
tion. He says that his chief trouble is in his chest. There is 
only one medicine that I know of that will help him, and that is 
saccharum lactis. He will have to take it pretty frequently, and 
diet strictly. Let him take a powder three times a day, and I 
think he will get over this tickling in his chest. 

After the patient had retired the Doctor continued : 

There is nothing much the matter with that man, but he fancies 
there is. You will find that patients who have suffered severely 
from certain forms of syphilis, and have had these sores cured by 
mercury, do occasionally have a peculiar form of monomania. You 
could see when that man came in, and began to take his shoes and 
stockings off, preparatory to stripping himself stark naked before 
you, that he had something on his mind. His pulse beats a little 
too rapidly, and he says that he has a pain in his head ; but I 
think there is nothing in particular the matter. You may set it 
down as a rule that when a man says that he can sleep well at 
night, that there is very little acute suffering. People with acute 
pains very rarely sleep or eat well. This man is a hypochondriac. 
Such men may tell you that they are suffering great agony, and 
their statements might lead you astray if you relied upon them 



90 HYPOCHONDRIASIS. 

alone. They may perhaps induce you to give medicines to relieve 
a pain when perhaps there is really no symptom to be relieved. 
They require mental treatment. This man fancies that he is very 
siok. We will give him no medicine ; and probably he will be 
back again. No class of men can exercise such an influence upon 
their fellows as physicians. When a physician once obtains the 
confidence of his patients, he can exercise over them an influence 
which no other man or woman can. It is often, by the exercise of 
this very influence on the mental condition, that you are able 
to perform very excellent cures. To prescribe for a. patient is 
not the only duty of a physician ; he should take a personal in- 
terest in every case ; and when the patient feels that an interest in 
his case is developed in his physician, he will feel bound to him, 
and will obey him. 

Many a man can go into an afflicted or distressed family, and 
with no medicine at all, but by his very presence ahme, and through 
the influence that he can wield by his mental power over the sick 
and the suffering, or over those who are in great trouble, make 
his presence like a sunbeam in the house. Recollect this, and try 
to cultivate elevation of the mind. Sir William Hamilton left on 
the walls of the old University at Edinburgh these lines — " On 
earth there is nothing great but man ; in man there is nothing 
great but mind." Act upon this principle, and you will be enabled 
to exert great influence over your patients ; and combine this 
with the proper administration of medicines, and you have in your 
hands a power which it is difficult to overestimate. 



j^utgical ffilinic of g} Member 6th, 1874 



Prof. Helmuth commenced by quizzing the class. 
Q. Which side of the body is the innominate artery ? A. 
Generally, the right side. 

Q. Please describe this artery. A. The innominate artery 
(brachio-cephalic) [anonyma], the largest of the vessels which 
proceed from the arch of the aorta, arises from the commence- 
ment of the transverse portion of the arch, before the left carotid. 
From this point the vessel ascends obliquely toward the right, 
until it arrives opposite the sterno-clavicular articulation of that 
side, nearly on a level with the upper margin of the clavicle, where 
it divides into the right subclavian, and the right carotid artery. 
The length of the innominate artery is very variable, but usually 
ranges from an inch and a half to two inches. 

Q. Describe the branches of the arch of the aorta. A. They 
usually arise from the middle or highest part of the arch, in the 
following order : First, the innominate or brachio-cephalic artery, 
which soon subdivides into the right subclavian and the right ca- 
rotid arteries ; secondly, the left carotid ; and thirdly, the left 
subclavian artery. 

Q. What is an aspirator \ A. An apparatus for drawing fluids 
from the body by the means of suction or vacuum. 

Q. Describe the inter-columnar or spermatic fascia \ A. This 
fascia is derived from the tendon of the external oblique muscle 
of the abdomen. On passing forward through the opening in 
that tendon named the external abdominal ring, the spermatic 
cord receives a thin membranous investment which is, as it were, 
continuous with the layer of so-called intercolumnar fibres, pass- 
ing obliquely across the upper border of that opening ; this is 
called the intercolumnar fascia. It is attached above to the mar- 
gins of the external ring, and is prolonged downward upon 
the cord and testicles. It lies at first beneath the superficial 
fascia, but lower down beneath the dartos, and it is intimately 
connected with the cremaster muscle and cremasteric fascia. 



Dorsum XXii. 



Henry Head, Aged Two Years. 

Prof. Helmuth. — You remember this case, gentlemen ; eight weeks 
ago Dr. Thompson put on a plaster bandage at the hospital. It is 
that of dislocation of the femur backward and upward, which occur- 
red when the child was four months old ; he was twenty months old 
when the plaster was applied. Four weeks ago L>r. Thompson 
took off the first plaster, which had been on for eight weeks, and 
used another. You will see that one leg is as long as the other, 
and he can walk, which he could not before. I cannot find that he 
was injured at any time, but the thigh moved in all directions — 
backward, and forwaid, and downward; it was very easily re- 
duced by this motion of the limb. (Illustrating.) We reduced 
the dislocation, and this leg was then made as long as the other 
one. As soon as there was a slight contraction we immediately 
advised the plaster bandage for its relief, and it has been success- 
ful. As the child grows it will be necessary to take off this splint 
and put on a larger one. You see he walks now very well. 

When we come to classify dislocations, gentlemen, you will 
find we have those occasioned by accident and those which are 
spontaneous. Spontaneous dislocations may arise from several 
causes. They are caused by musclar contraction, shallowness of 
the cavity in which the head of the bone rests, and again from 
some disease between the head of the bone and its articular surface. 

The result of the treatment has been very satisfactory indeed. 
There is no disease about the bone ; it seems to be merely a dis- 
location backward and upward, and if you had seen it, you would 
have seen — what? A shortened leg, the knee of the affected 
side turned over towards the opposite knee. It was not only 
a perfect illustration of this dislocation, but it afforded, also, 
an illustration of the manipulation treatment of reduction. It 
could be reduced directly by this simple manipulation which is 
now being introduced so considerably into surgical practice, 
viz : Flexion adduction, circumduction, and extension. 

Since the introduction of anaesthetics there is no need, in the 



POTT'S DISEASE OF THE SPINE. 93 

majority of cases, of applying the same force that was formerly 
necessary to reduce the hip, and it is found sometimes that gentle 
manipulation may succeed, even in a strong and powerful man, 
where the pulleys have not had any effect. It used to be the 
fashion to bleed or to administer tobacco infusion until the muscles 
were relaxed. This is all done away with ; there is little counter- 
acting tendency in the muscles and tendons in reducing dislo- 
cations. 

This case not only is a beautiful illustration of spontaneous dis- 
location, but it shows how easy is the reduction. You flex the 
leg upon the thigh and the thigh on the abdomen ; then grasp 
with your right hand the leg above the ankle, with the other hand 
take hold of the knee — you ad duct it, make rotation, and then 
extension. 

These manipulations can be employed in all dislocations, 
especially those of the hip. After this bone was reduced a 
plaster of Paris splint was applied, which in eight weeks it was 
necessary to remove. It is a very successful case, indeed, and a 
fine representation of what may be done with the immovable 
apparatus. Without this the patient would perhaps have become 
an invalid, or else would have been obliged^ to lie in bed with a 
weight at his foot. The plaster splint has effected a radical cure. 
You may recollect that in children the immovable apparatus is 
one of the very best that can be employed. 






Elizabeth Gerhardt, Aged Four Years. 

{Continued from page 24.) 

It is ten weeks to-day since she came here. She comes from 
Staten Island. This disease is certainly growing better all the 
time. She has now been taking calcarea for a considerable time, 
and I will continue it at least three weeks more. 

In these cases, of course, the improvement is extremely slow, 
and it takes years before a cure can be accomplished, but I have 



94 POTT'S DISEASE OF THE SPINE. 

every reason to hope that you will see a diminution, in the 
projection of the spinous processes, and that the majority of the 
symptoms will be relieved. The object of the apparatus that you 
see bound to the back is to take off pressure, and that is accom- 
plished by these crutches, which support the arms and are attached 
at the waist. Now, in some instances, this variety of splint is 
unbearable, and we have to content oiu-selves with medicine. 
Then, again, there is another form of splint, which those in bet- 
ter circumstances can procure ; it is called " Darraeh's Wheel 
Chair Crutch." It resembles a woman's petticoat or hoops, held 
upright, and padded under the arms. You take a child and 
place it in the centre of the apparatus, and the padded parts 
come directly under the arms ; it takes the entire weight of the 
body off the spinal column. I know of three cases which have 
been cured by this apparatus. It was invented by Mr. Darrach 
for the cure of his own child. 

Dr. Burdick has now a case of Pott's Disease which has been un- 
der his care for two years. He will give you the history of the case. 






¥m. Wood, Aged Six Years. 

Prof. S. P. Burdick. — Three years ago this little boy was first 
shown to me by his mother, and he was then suffering from the first 
indications of Pott's Disease. I advised a course of treatment, but, 
as this lady says, I " did not talk quite enough," always when you 
have any thing to say to the ladies be sure and do talking enough. 
The case was then submitted to Dr. Taylor, who is a very skil- 
ful physician, and he applied a splint, which the child wore for 
nearly a year, when the case was again presented to me without 
any perceptible improvement. I then advised the mother, as the 
brace had been properly adjusted, to continue its use, and placed 
the child under treatment. He has been under treatment for two 
years constantly; there has been no intermission, I believe. He 
has not failed, I think, a single day, to take the remedies which 
were prescribed in his case, and, during the past year, the mother 



STRICTURE OF THE (ESOPHAGUS. 95 

tells me. she lias heard no complaint from the boy whatever, al- 
though he still wears the splint, and seems perfectly well. The 
remedies which he has taken, from the first to the last, have been 
calcarea carb., 200; one dose at night, six globules, and calcarea 
phosphorata in the morning, ten globules. This has been his 
treatment from the beginning to the end. At the time he first 
came under my care he was having from ten to twenty passages 
from his bowels a-day, which Dr. Taylor informed the mother 
would have to wait until the spinal trouble got well, and then the 
disease wouldd isappear. Under the treatment of calcarea he 
gained a visible improvement at the end of six weeks. The trouble 
has decidedly improved, and his general health and strength was, 
from that time to the present, greatly improving, without any in- 
termission whatever. 

Now, you see, the character of this brace is very much better 
adapted to the case than that of the patient you last saw, but this 
is a very much more expensive article. He was five years old 
last August, and he continues to grow tall. 



Henry Nichol, Aged Sixty-two Years. 

( Continued from page 74.) 

The next case is that bad case of spasmodic stricture of the 
oesophagus. 

Prof. HelmuHi. — It is two weeks to-day since he was here. 
(To the patient) — 

Q. Can you swallow this morning I A. Yes, sir. 

If you recollect, I tried to explain to you the nature of these 
spasmodic strictures, and I prescribed then cocculus the 30th, and 
ordered hot applications about his neck, and that hot drinks be 
taken. He says his throat feels better. He has been taking coc- 
culus the 30th for about two weeks. There is an evident improve- 
ment in his CDndition, and, as I said before, cocculus has a specific 
influence on the muscles of the oesophagus and pharynx, and he 
states now, that from the relaxation of the upper part of his throat 
he begins to feel more comfortable. The law in medicine is, 



96 STRICTURE OF THE (ESOPHAGUS. 

to let well enough alone, although the temptation is, when you 
have a case that is doing well, to change the medicine or to resort 
to other means. Particularly with young practitioners is this a 
strong temptation; they prescribe for a patient and think that the 
medicine must act in a short space of time, and if very deeply in- 
terested in the case, they think their reputation is at stake. I was 
so. When a young practitioner is called to a case, he is very 
anxious for its success, and he studies it up very thoroughly, and 
finds the medicine he thinks is proper ; he gives it to the patient, 
and expects to see immediate relief. If the expected improve- 
ment is not immediate, he takes down the books, supposes he has 
given the wrong medicine, and goes back the next morning and 
changes it. But I began to find out, as I grew older, that it was 
a good thing in medicine to let well enough alone, and to give the 
medicine opportunity to act. One reason why doctors can never 
treat their own families successfully in severe cases, is, that they 
knoiv too much. Yery often physicians think they overflow with 
wisdom, but when they come to prescribe for their own families 
their egotism falters. They give a dose of medicine to their 
child, they take out the books • and find another remedy which 
they think better than the first, and so they desire to change the 
prescription. There is another thing to be remembered ; when a 
patient is getting better by nature, if you have common sense, let 
nature continue, you can have the honor all the same. Don't 
interfere with it. The law is, and write it down, that when a 
patient is improving, continue the same medicine until you are 
sure it has exhausted itself, and when the patient begins to get 
worse, do not think it is an aggravation for the Lord's sake. 
Many split on this rock. Nothing makes me so angry as to 
have a person come into my office and say, " Doctor, I have been 
worse ever since I took that medicine," where I know medicine 
had nothing to do with it. 

As to this patient, he is getting better, and I believe cocculus 
will relieve this stricture, so I will continue it for two weeks more. 
We will go on and give you this medicine and you will come back 
in two weeks. He asks me if I am going to put something into 
his throat. I will not. I never, in spasmodic strictures, put 
instruments into cavities where there is a liability to spasm ; 
that very often aggravates the case. I say that it is a triumph of 
surgery if you can by internal administration of medicine cure a 



STRICTURE OF THE (ESOPHAGUS. 97 

disease which formerly was treated only surgically. I do not 
mean to put any instrument in your throat to-day; but you 
must come back in two weeks. If you should get worse, come 
next Saturday ; but, if you think you are getting better, stay two 
weeks. 

The great fault of teaching in medical colleges is this — that 
you are led to believe, when you are called to see a case of 
disease, it will be easy to diagnose and to treat. The descrip- 
tions are so simple in the books that little difficulty is apprehended 
by the student as to his capability to perform professional duty. 
This is wrong. Often in diseases there is such a similitude that 
it takes the closest power of discrimination and the greatest 
wisdom to diagnose one from another. You think it is easy to 
diagnose a dislocation of the lower jaw. Yet even this has been 
mistaken. There are difficulties in all cases, but the man who 
overcomes the difficulties, makes the best physician. The greater 
the difficulty on the one hand, the greater should be the incentive 
to study on the other. Don't'you dare, when you have gone home 
after curing a simple case, to think that you are a great doctor ; 
because you are not, for diseases get well of themselves. Take a 
bad case and bring that through all right, and then you can prove 
yourself competent. When you are an M. D., when you think 
you have passed through the green room and are regularly em- 
powered to encounter all the diseases with which the world is 
affected, do not, because you cure one or two of them, think you 
are a great man. 

• The next case we will have is a small tumor over the eye. It 
is not much, but it is the little things in this life that make the 
great ones ; it is the atoms which make the world ; it is the 
motion of those particles which make light, heat and electricity, 
and the man that disregards the little things in life, is not the man 
that can overcome the great ones. 



Hattie Andrews, aged 15 years. 

Here is a tumor that lies directly over the external canthus of 
the eye. Sometimes these smail tumors which grow in the neigh- 



98 OPERATION FOB SEBACEOUS TUMOR. 

borhood of the frontal bone, or skull, from the pressure they 
exert, have a tendency to absorb the bone, and a tumor like this 
one pressing down so on the bone may absorb it. This is a 
favorite way to remove them. Raise the skin, like that, and 
then enter the knife, with the back downward, and cut from 
within; that makes a clean cut down through the tissue. After 
you have made your incision, take a pair of forceps, and raise up 
the skin. These things stick very tight sometimes, and are some- 
times very difficult to get out. (The tumor was dissected out.) 

Sebaceous tumors have different kinds of sacs. In some yon 
have seen the envelope is very thin ; in other instances the sacs 
are perfectly firm and hard ; and still in other instances they ad- 
here not only to the superimposed structures, but also those 
below. This patient now should be principally treated with cold 
water dressing. No, do not give her any medicine. I know she 
will get well without, and if I were to give her medicine and she 
were to recover, I might s appose that I was very scientific. 
Common sense in medicine, is a great thing, gentlemen. The 
trouble is, we are apt to lose our common sense when we come 
to s[et too much science. It is not the most studious physician 
who makes the best practitioner. It is an acknowledged and ac- 
cepted fact that the most distinguished men in the profession for 
their learning, are often the least practical when they come to 
the bedside. 
Prof. Helmuth [To a student of the class] : 

Q. Now, sir, ether you say is an anaesthetic. Who introduced 
it ? A. Dr. Wells, of Hartford, Conn. 

Q. Are you sure it was Dr. Wells? What about Dr. Morton ? 
See page 17. 

Q. Who introduced chloroform? A. Prof. Simpson, of Edin- 
burgh. 

Q. What are the rules for giving ether. In the first instance, 
must the patient have a full or empty stomach when he takes 
ether? A. An empty stomach. 

Q. Then what is the next thing. This gentleman says they must 
let atmospheric air in where apatient is anaesthetized ? A. It is not 
necessary. The rule for the administration of ether is this : 
that if the ether be pure, there is no necessity for atmospheric 
air. The best precaution is to have the patient fast for at least 
three hours, and after fasting he should have, about half an hour 



ANAESTHESIA. 99 

before administering the ether, a stimulus in the shape of brandy, 
or about eight to ten grains of bromine of potassa. Then the 
anaesthesia must be carried to insensibility. 

Spencer lays it down as a law, and as one of the principles, 
that he never pushes anaesthesia to more than insensibility. 
When a purple skin and stertorous breathing appear, then it is 
time that it should be suspended. 

With chloroform the case is very different. In chloroform there 
must be always an admixture of atmospheric air ; the patient 
to be watched carefully and very closely. Fluttering of the 
heart and spasmodic breathing are bad signs with chloroform, and 
the trouble is just here — a patient may pass from life to death 
before the operator is scarcely aware of it ; and a patient in 
apparently good health may take his seat in the chair, and the 
chloroform may affect him in such a manner as to make death 
imminent, or he may expire at once. It is for this reason that I 
am opposed to giving chloroform, except, perhaps, in cases 
where it seems to act remarkably well, such as the relaxation of 
the muscles in obstetrical practice. I argue that it is better 
for the operator, that the patient take ether, than to run the' risk 
of a sudden death. From ether you have the stage of insen- 
sibility coming slowly, it is true, but still it is a better and a safer 
practice to resort to than the use of chloroform. If I am operating 
on a patient under chloroform, I have to be thinking of the 
chloroform as well as the operation ; but if I am practicing with 
ether, I am free of care, and that is a great deal. 



Surgical filmic of Qmmbtt 12th, 1874. 



Prof. Helmuth to the Class. 

Q. What is the difference between phymosis and paraphymosis i 
A. Phymosis is a preternatural constriction with elongation of the 
prepuce, in front of the orifice of the urethra. Paraphimosis is 
the reverse of phymosis — the prepuce becoming retracted behind 
the corona glandis, leaving the glans uncovered. 

Q. How many stages of hip disease are there ? A. Three dis- 
tinct stages. 

Q. How is the foot in the first stage ( A. It is generally not 
much altered in position. 

Q. How is the foot in the second . stage % A. Abducted and 
rotated outward. 

Q. How is the foot in the third stage \ A. Assumes a posi- 
tion directly opposite to that noticed in the second stage. It is 
rotated inward, shortened and abducted; the toes only touch the 
ground. 

Q. What is the difference in the diagnosis between fractures and 
dislocations ? A. In fracture there is increased mobility, crepitus, 
and when the broken extremities are placed in apposition, they will 
not thus remain without external support ; while in dislocation or 
luxation there is unnatural rigidity, and the displaced part re- 
mains fixed. There is likewise discoloration, pain, and swelling; 
at times, temporary paralysis. The limb is shortened, very 
seldom lengthened. When the dislocated end of the bone can be 
felt, it will be found in an unnatural location, and a depression 
be detected in the place that the extremity of the bone occupied. 



Thomas Whiting, aged 26 years. 

History of Case. — Lost his arm ten years ago, by machinery;. 
The arm was caught in a belt and taken round a shaft. Amputation 
at the middle third took place three days after. The stump now 



NEURALGIA OF THE STUMP. 101 

pains him all the time, and lias for the last two years. The suffer- 
ing is worse at night than in the day. The cicatrix has contracted 
on the end of the bone. There was no pain for a number of years 
after the operation ; but the parts began to be sensitive when 
the integument began to contract over the bone. At the time of 
the amputation, mortification was rapidly extending up the arm. 
Prof. Helmuth : 

. That arm is a very good text for two or three lectures. In the 
first place, it is a good, text to speak from, with reference to 
what is called traumatic gangrene.. You will recollect that, when 
I was speaking of the terminations of the inflammatory process, 
I stated that in dry gangrene or in the ordinary forms of mortifi- 
cation, it was necessary, before amputating, to wait for the 
line of demarcation, and that in other cases, it was just the con- 
trary ; and when we had traumatic gangrene, which extended 
rapidly, and the life of the patient was at stake, amputation 
should be performed, and the sooner the better. If you will put 
your finger on the end of this stump, you will feel that the bone 
lias been sawn off diagonally, that the bone is sharp at that ex- 
tremity, that the tissues have adhered thereto, and that there has 
been a contraction of the flap. There is a difference of opinion 
as to the period and point .of amputation in traumatic gangrene. 
Particularly in those injuries which result from machinery, where 
the parts are bruised, and crushed and lacerated to a pulp, and 
there is no way whatsoever to relieve the patient, and the gan- 
grene seems rapidly extending itself — then to wait for the line of 
demarcation is to wait for death, and to give the patient over to it. 
If, on the other hand, we have dry gangrene, then it is wrong to 
perform an amputation until the line of demarcation is fully formed. 
In such gangrene as this man had, amputation must be resorted to 
within one or two days. There may be a primary amputation 
performed; but after an amputation, no matter how skillfully 
performed, certain untoward results may follow. For a con- 
siderable period of time after an amputation a patient may con- 
sider himself cured; but some unhealthy action may take place in 
the stump, which gives rise to intense pain, which may be easily 
accounted for. There is a great tendency in all tissues during 
the healing process to contract, and during contraction there is a 
tendency to adhesion to the end of the bone. This patient says 
that for seven or eight years he enjoyed perfectly good health, 



102 NKI RALGIA OF THE STUMP. 

and but little pain. Then, two or three years ago, he began to 
feel pain and soreness on the under surface of the firm, and then 
he referred his Buffering to the amputated fingers. There is 
frequently this peculiarity attending amputations — that the patient 
seems to have sensibility conveyed to his brain through the 
stump, as it was through the limb before it was taken off; and 
sensations at the end of the fingers are apparently felt as well as 
they were before the arm was amputated. Here has been a 
contraction of the cicatricial tissue, and an adherence to the 
bone; and as the tissues adhered to the bone, they embraced 
within them certain filaments of the median nerve. The median 
nerve on the under side of the arm is included in this cicatrix, 
and therefore he will tell you that he has all these nervous 
sensations. In other words, he has neuralgia of the stump, 
which is worse at night, which gives him apparent sensitiveness at 
the end of the fingers, and which is always aggravated in bad 
weather. He can tell by that stump when a storm is coming. 
The pain is always worse at night, and is then of a shooting and 
darting character. 

What can we do to relieve this neuralgia of the stump ? If 
it is simply idiopathic, and caused by the division of the 
nerves ^lone — if there are no mechanical troubles connected 
with it, there are medicines which will be of the greatest possible 
service to relieve the patient. I may mention here, that during 
the battle of Waterloo the Marquis of Anglesy had his leg shot 
off ; it was amputated on the spot, but for five years he suffered 
very severely from neuralgia of the stump, trying many remedies 
to relieve the pain, but all in vain ; and I assure you that this 
pain is almost unbearable at times. Finally he sought Hahne- 
mann in Paris, and by him was cured of the neuralgia by in- 
ternal medication. That is a fact in history, and there is no 
denying it. In a case like this, however, where the nerves are 
involved in the contracting tissue, other means may have to be 
resorted to, to produce the desired effect. Before I speak of the 
mechanical causes of this neuralgia of the stump, I will relate a 
case of the affection wdiich was cured by the use of a medicine 
but little known. 

I was called across the river to see a man suffering from neu- 
ralgia of the stump. He had recovered from a thigh amputation ; 
the stump had healed, and seemed sound, and yet the pain he 



TREATMENT FOR NEURALGIA OF THE STUMP. 103 

suffered was perfectly appalling. He had tried a great many 
medicines, such as belladonna, the acetate of copper, ign., cicu., 
zinc;, hydrochlorate of amm., morphia, and others of that class of 
medicines which act upon the nervous system, and which, ac- 
cording to the symptoms in each particular case, will often produce 
relief. In this case, however, all the different remedies were 
tried without avail, and the patient was in such despair that he 
often thought of committing: suicide. He had tried manv doctors, 
of all schools, and had given himself up as a hopeless case. He 
was a great smoker, and as he stooped one clay to light his pipe 
from a scrap of French newspaper, he read of a case of neuralgia of 
the stump which had been cured by eating onions. He immedi- 
ately sent out and procured three large ones, and ate them ; and for 
the first night 'in two years he slept. He continued this treatment 
for several days, and was able to sleep every night. Then he 
thought he avouIcI try the tincture of allium cepa; and he took 
the tincture with almost the same effect. He got into the habit 
of eating an onion every night before going to bed ; and finally 
cured himself of the neuralgia. This medicine, therefore — allium 
cepa — must be put down as one of those for neuralgia of the 
stump, and it is w^ell to recollect it. 

With respect to the patient before us, it would seem that we 
must do something to prevent further contraction of that cicatrix. 
We will give him some internal medicine, and apply a lotion to 
the stump. If that does not do, and the pain becomes aggra- 
vating, the adhesions must be loosened from the bone by an 
operation. That will certainly relieve him, and then internal 
medicines must be given. If a mechanical obstruction is the 
cause of the neuralgia, we must resort to mechanical means for 
relief. I will prescribe for two weeks : the tincture of allittm 
cepa, five drops, to be taken four times a day in a tablespoonful 
of w T ater ; and I will have applied to his arm at night a simple 
onion poultice. Take a good sized onion, chop it up fine, put it 
into a rag, and tie it on to the stump at night. 



iProkea Needle* 



Maria Reed, aged 16 years. 

With a broken needle in her hand. 

She has the blunt end of the needle in her hand; and if it 
were within reach, and you could determine its position, it would 
be high time then to cut down and take it out. But now I 
cannot even feel the needle, and do not know where it is located, 
and it would be improper to make an exploratory operation 
in the palm of the hand in search of it, when we do not know 
in what direction to probe. Needles have entered the palm of 
the hand, and have come out at the shoulder ; they have entered 
at the knee, and I have taken them out at the chest. And so 
with bits of glass and splinters. Metallic substances, especially, 
have a tendency to wander through the system. Until this needle 
comes nearer the surface it would be wrong to meddle with it. 
She will feel it somewhere near the surface after awhile. It may 
move quite fast. As it does not give her any inconvenience, it is 
better to wait until it makes its location known. She need not 
worry herself about it, for it will not hurt her. This looking for 
needles when you don't know where to find them, is a very un- 
satisfactory thing, and very unsuccessful. 



Siy+^frittt $>i8*&*«c 



Katie Paulding, aged 3^ years. 

History of Case. — Has been lame since she had a fall, six months 
ago. She was standing in the door, a dog ran under her and 
pushed her legs apart, and she fell heavily on the floor. She im- 
mediately arose, but walked lame, and has been lame ever since. 
For two weeks she has not been able to walk at all. She has a 
great deal of pain at night. 
Prof. Helmuth : 

This is a rapid case of hip disease. You observe one foot is 
turned out, and the leg seems longer than the other. She com- 
plains a great deal of pain in the knee, and the mother supposed 



HIP-JOINT DISEASE. 105 

that the injury was in her knee, until Dr. Thompson told her 
that it was in the hip. This patient fell and bruised the articular 
•cartilages, and from that time to this, inflammatory action has 
been taking place. The leg has a tendency to turn out, and is 
half to seven-eighths of an inch longer than the other. If this 
patient had been taken in hand the moment she fell, and put on 
her back, an application of arnica applied to the hip, and arnica 
administered internally, the disease would probably have been 
prevented. But the parents of the patient, not knowing the re- 
result of exercise in an injury to the hip, did not have any thing 
done, and permitted the child to exercise as usual. The pain 
increased and became aggravated at night, and it must now be 
looked after, because it is almost impossible to arrest the disease 
after it proceeds to the second stage. Tin's child must be kept 
on its back. Every pressure, every motion of the head of the 
bone in its socket, has a tendency to bring together two surfaces 
which are already inflamed and irritated. Put the patient in 
bed ; but for the present apply no extension, because I am not 
quite certain whether or not the effusion has yet taken place. 
Give the child perfect rest, Apply arnica on the outside and in 
ternally, and also the 3d trituration of lithia. This is recom- 
mended in the first stages of hip disease ; although I have not yet 
had any experience in the use of it. 



Hij^Joint Disease. 

Albert Sissmann, aged 12 years. 
{Continued from pages 60 and 85.) 

[Boy enters walking, and moving well.] 

You will recollect that this boy has been here before fur hip 
disease. I will to-day show you the principle upon which this 
splint acts. There are a great many splints which are made and 
applied for hip disease. This is a plain splint, and is what is 
called Bauer's splint. I use it very often for this class of cases, 
because many of the other splints require to be held in place by 
adhesive straps, and it takes a great deal of care to keep them 
adjusted. Here is a crutch, and a strap so arranged as to create 
counter extension. Here are two cylinders which are attached to 



106 NuEVUS — HBfiNIA. 

the shoe, and are so arranged that by turning the key you can 
draw one from the other and thus make extension. You can see 
the foot move as I turn the key. He turns the key every day. 
Yon can see that his foot is now brought almost to the floor. 
You also see an immense improvement in his general health. 

There is another splint which is a very excellent one, and that 
is the splint of Dr. Taylor. In that, the foot does not come to 
the ground at all. An iron extends below the shoe, and the 
patient walks on the iron. There is no jar given to the foot, for 
all the weight comes on the iron bar. Then there is the splint 
of Dr. Sayre, made on the same principle, with the exception that 
it has no shoe nor bar, and is held by adhesive straps. Then 
there is the old splint of Dr. Davis, who was the originator of 
these splints^ and the first man who gave an impetus to the ap- 
plication of extension and counter-extension in hip disease. 



Ida Teller, aged 5 months. 
( Contin uecl from -page 13.) 
We have here the child with the nsevus that was operated upon 
at the first clinic this winter. It has now been healed up for 
about three weeks. She is brought here to-day to satisfy your 
curiosity. It has certainly very much improved in condition 
since it was operated upon. 



John Thomas Parry, aged 6 years. 
Prof. Helmuth : 

It always gives me a great deal of pleasure to show a case of 
rupture, for it gives great facilities for " quizzing " you about it ; 
and as I have said before, I enjoy these examinations probably a 
great deal more than you do. 

This child was born with this rupture. It is not a hydrocele, 
for hydrocele begins at the bottom of the scrotum ; hernia begins 
at the top. Hydrocele has no cough impulse ; hernia has a cough 



HERN r A. 107 



impulse. Hydrocele is translucent, when we hold a lamp behind 
it; hernia is not, except in certain cases. Inversion of the body 
sends the hernia up, but when the patient resumes his position 
the hernia returns. If you had hydrocele, you might hang by 
yoin- feet forty days and it would make no difference with the 
tumor. There is in this child a predisposition to hernia. He 
has congenital hernia. I should advise this patient, with such 
rings as those, to undergo an operation for its relief. You know 
that there is what is called the radical cure for hernia ; but it is 
not adapted to all the varieties.. But in such a case as this, where 
the. rings are so large, I think that it is" advisable to try the rad- 
ical cure operation. The ring is so extensive that, as. you see, I 
can pass my finger into the internal ring. It woidd be almost im- 
possible to keep this gut up with a truss, the rings are so distended. 
The method of performing the radical cure is simply this : You 
pass a needle, threaded with wire, through the internal pillar of 
the ring, bring it out, twist it; turn it back through the external 
ring, bring it up again and twist it. This sets up sufficient inflam- 
mation to invaginate the scrotum. That is after Wood's method. 
Wurtzer's method consists in taking a plug of wood made on pur- 
pose, with a needle to run through the block. You push the 
block into the scrotum and hold it there; then push the needle 
out through the abdominal wall, and screw a clamp on top of the 
needle in order to retain it until suppuration is established. 

What can be done in this case. If allowed to remain as it is, 
it will strangulate, and give him a great deal of trouble. If he 
grows up, it will still give him a great deal of anxiety. There- 
fore, I advise that an operation be performed on the child. He 
will have then to be kept very still. It is an operation not always 
free from danger; but, at the same time, it affords the best means 
of being permanently cured. Take the child home and talk to 
his mother about it, and then come and see us again. If you do 
not conclude to have it performed, we will then do the next best 
thing. But it has gone so far that I think the radical cure 
operation is the better. 

Recollect, that there is congenital hernia and acquired hernia; 
and that it is not necessary that congenital hernia should develop 
itself at birth. 



Sefcaeeous T%U»QSP» 



Hattik Andrews, aged 15 years. 

{Continued from jxuje 97.) 

Dr. Thompson says that lie was sent for on Sunday night to 
see the patient; found the right eye swollen up and closed, and 
suspected erysipelas; the pulse W T as at 120; and he prescribed 
aconite and belladonna. On Monday night, the eye was still 
more swollen. Forty-eight hours after the operation the inflam- 
mation had extended to both eyes. He withdrew the sutures, and 
there came away at least two tablespoonsful of sanguineous pus. 
The wound gaped open. At the time of the operation there was a 
small artery which bled considerably, and was not tied, hoping 
that the hemorrhage would stop without a ligature. But there 
was some secondary hemorrhage, and the wound filled with blood 
and pus, so that it was necessary to open it. Afterwards slight 
compression was made with plaster ; and now she is doing very 
well. She was brought here on Tuesday morning, and has been 
here ever since. She can now open her eye, and there is 
scarcely any swelling. These sebaceous tumors sometimes 
undergo a spontaneous cure. Sometimes an inflammatory action 
sets up in the sac and the contents are discharged. But then 
there generally remains an unsightly scar. Therefore make it a 
rule, in removing sebaceous tumors, to remove as much as possi- 
ble of the cyst wall, or else you may have a reproduction. But 
the cyst is not of sufficient importance for you to remove it 
altogether, if portions of it lie in very close proximity to im- 
portant structures, because, if you remove three-fourths of the 
cyst, in a majority of cases, the other one-fourth will pass off with 
the discharge. In the performance of the operation you must 
never injure any other part. That is a law, you must always fol- 
low, in whatever operation you perforin. 



jtargtatl ®ttn« of Qtttmbtv 19th, 1875. 

. _ ^-..- ---■.-. . < « > . . ^--^^^^- 

Prof. Helmuth quizzes the class on hernia abdominalis or abdom- 
inal hernia. 

Q. What do we understand by hernia! 1 A. Protrusion of the 
contents of any cavity of the body. 

Q. What is the difference between congenital and acquired 
hernia \ A. Congenital hernia may occur soon after birth. At 
this time the intestine or omentum passes out of the abdomen, ac- 
companies the testicle in its descent, and becomes lodged in the 
pouch of peritoneum which forms the tunica vaginalis testis 
before its communication with the general peritoneal cavity has 
become obliterated. Acquired hernia occurs from lifting, straining, 
or making violent muscular exertions of any kind. 

Q. What is an inguinal hernia? A. It is that in which the 
bowel protrudes at the groins or through the abdominal rings. 

Q. What is a direct inguinal hernia \ A. It is that in which 
the bowel protrudes through the abdominal wall and the external 
ring. 

Q. What is oblique inguinal hernia \ A. The bowel protrudes 
through both rings and through the inguinal canal. 

Q. What is the difference in the coverings of the oblique and 
direct inguinal hernia ? A. They are the same, except in the 
direct, the conjoined tendon is substituted for the cremasteric 
fascia. 

Q. If we find that we have a tumor beginning at the bottom of 
the scrotum, how would you diagnose whether it were a hernia 
or a hydrocele I 

1. Hernia is almost invariably opaque, 1. Hydrocele simulates hernia, but dif- 
the only exception being in case of a large fers from it by being niore or less trans- 
fold of intestine distended with gas and lucent. 

covered by thin integument. 

2. The tumor is always varying in size, 2. The tumor is constant, 
and can generally be made to disappear 

by pressure. 

3. The cord can never be distinctly 3- A part of the cord can be felt dis- 
felt in any part. tinct from the tumor at its apex. , 

4. The tumor is enlarged upon cough- 4. Hydrocele, unless congenital, does 
ing or exertion. not enlarge upon or feel the impulse of 

coughing or exertion of the muscles 

5. The testicle can be felt distinct and 5. The testicle can scarcely be felt, if 
separate from the tumor at the lower at all. 

part of the scrotum. 

6. Hernia appears suddenly, is de- 6. Hydrocele forms gradually, and is 
veloped from above and descends. developed from below upwards. 



110 QUIZZES ON IIKKNIA. 

Q. How would you diagnose varicocele from hernia ( A. In 
the varicocele the swelling is not reducible, and has the feeling 
as of a bunch of worms. . 

Q. What is the difference between enterocele and epiplocele \ 
A. In the first the intestine alone is displaced ; in the latter, the 
omentum alone is displaced. 

Q. What is entero-epiplocele ? It is that in which both the 
intestines and omentum protrude. 

Q. What is encephalocele ( A. Hernia of the brain. 

Q. What is pneumocele '? A. Hernia of the thorax. 

Q. What is reducible hernia \ A. One in which the pro- 
truding bowel may be replaced into the cavity from which it 
came, either spontaneously or by taxis. 

Q. What is irreducible hernia \ A. When there exists a pro- 
trusion of the bowel which cannot be returned to the abdomen. 

Q. What is strangulated hernia \ A. It is that form of hernia 
in which the bowel is so pressed upon at the point where it 
passes through the walls of the abdomen," that it is strangled or 
constricted, which prevents the contents of the intestines from 
passing to the anus, and the venous circulation is impeded. 

Q. What is crural or femoral hernia ? A. It is a dropping 
down of the bowel behind Poupart's ligament, and appearing as 
a tumor at the upper part of the thigh. 

Q. What is the difference in diagnosis between femoral and 
inguinal hernia? A. In the femoral hernia the finder can be in- 
troduced into the inguinal canal. Poupart's ligament cannot be 
made out, even though the gut has ridden over it. An inguinal 
hernia lies inside of the spine of the pubis. 

Prof. Helm nth said : 

Psoas abscess may, in rare instances, be mistaken for femoral 
hernia. 

But the many presenting symptoms of spinal disease, the slow- 
ness and variability of progress, the fluctuation, and the part at 
which the abscess points, which, in the majority of cases, is out- 
side, of that which hernia protrudes, serve to form the distinctions 
necessary for diagnosis. 

An enlarged gland has been mistaken for hernia by most dis- 
tinguished surgeons. Hamilton records a case in which several 
days elapsed before the diagnosis was made out, the delay causing 
the death of the patient. Sir Astley Cooper also mentions two 



QUIZZES OX ANEURISM, HEMOSTATICS, AND TETANUS. Ill 

fatal cases of the kind. The absence of cough impulse, the sol- 
idity of the tumor, history of the case, and the constitution of the 
patient, must be our chief guides in these cases. 

Q. How would you diagnose sarcocele from hernia ? A. By 
absence of cough, impulse, and the non-implication of the sper- 
matic cord, and the history of the case. 

Q. What do you understand by the term Aneurism ? A. A 
pulsatory tumor, which is filled with blood, partly fluid and 
partly coagulated, and whose cavity communicates with the 
arterial canal. 

Q. "What do you understand by the term True Aneurism ? 
A. It is formed by the dilated coats of an artery forming a pouch, 
or sac ; this sac is composed of all the arterial coats. 

Q. What is the difference between a true and a false aneurism \ 
A. By true aneurism we mean a partial dilatation of all the coats 
of the vessel. By false aneurism we mean expansion of the one, 
the rupture of the other. 

Q. How is the dilatation of aneurism classified \ A. Into 
cylindr 'oicl, fusiform or sacciform. 

Q. What is the difference in these three dilatations of aneu- 
rism ? A. In cylindroid the expansion is abrupt and uniform. 
In fusiform the enlargement is spindle-shaped. In sacciform 
the. dilatation is partial, and arises from the side of the vessel. 

Q. What is hemostatics ? A. The arrest of bleeding. It 
may be natural or may be artificial. 

Q. What do we understand by torsion ? A. Twistino- of ar- 
teries to arrest bleeding. 

Q. What is tetanus i A. Permanent spasmodic contractions, 
or spasm of the voluntary muscles of a portion or nearly the 
whole of the bodv, rendering it stiff and straight. 

Q. How many kinds of tetanus are there ( A. Idiopathic, 
produced by exposure to cold; and traumatic, produced by bodily 
injuries, particularly the injury of a nerve. 

Q. What is trismus I A. When the spasm presents itself in 
the muscles of the neck, throat, and jaw. 

Q. What is opisthotonos ? A. When the muscles of the back 
are affected, the patient is drawn backward into the shape of a 
hoop, and rests on his head and heels. 

Q. What is emprosthotonos ? A. It is exactly an opposite 
condition of episthotonos, the body being bent or drawn forward. 



112 CASK OF HYPOSPADIA AM) RETAINED TESTICLE. 

Q. What is pleiirosthotonos 2 A. It is wlien the muscles of 
the side of the body are affected with tetanic spasm. 



ttyjpoajp**** ■*«*<* Strained 

Q. What is hypospadias ? A. When the urethral opening ter- 
minates or exists in the course of the canal on the lower side of 
the penis. 

Q. If the urethra terminated on the upper portion of the 
penis, what would it be called ? A. Epispadias. 

I propose to present to the class to-day a case of hypospadia, 
with retained testicles, which has been operated upon once or 
twice, without success. I might say that all operations are 
nearly useless in this class of cases. This youno- man has been a 
student of medicine, but has been rendered unfit for work by 
this deformity. Both of his testicles are retained and sore. In 
a majority of instances the operations in such cases are unsuc- 
cessful. I bring him before you to show you an aggravated case 
of hypospadias, and at the same time to state a very peculiar fact,, 
which is this: that this man has all the sensation of passing 
semen, as if his parts were in a normal condition, and that the 
sensation is attributed or referred by him to the end of the 
penis. The semen and urine pass through an opening in the 
membranous portion of the urethra. The patient has been opera- 
ted on by Dr. Tiffany, of Baltimore, but the operation was not 
successful. The opening is now in the perinseum. The patient 
is very destitute, and I thought that I would bring him before 
the class, that you might have an opportunity of seeing the case;, 
and if any of you choose to assist him, with ever so little, he will 
be grateful. I shall therefore ask him to exhibit himself to you. 
It is rare that you can see such an aggravated case of hypospadia,, 
and this complicated as it is with by retained testicles. 

Patient is brought in. 

Henry Wilson, aged 37 years. 

Q. You have had this malformation from birth ? A. Yes, sir: 
from my birth. 

Q. Before you were operated upon, how far back in the 



COLD ABSCESS. 113 

urethra was the opening through which you passed water I 
A. Three and a half inches. 

Q. As you came from boyhood to puberty, did von have sex- 
ual desire ? A. Yes ; and rather prematurely. 

Q. The scrotum was well developed before the operation i 
A. Not very well. There was some redundancy of tissue. The 
testicles never came clown. 

Q. When you have emissions of semen, do you have pain in + he 
testicles ? A. Not at all. 

Q. Do you have any unpleasant feeling in the testicles i A. 
Yes, preceding the emission. It makes the left testicle painful a 
long time before there is an emission. 

Q. Then you do not have any such trouble in the right testicle i 
A. I have no evidence of any right testicle having an existence. 
I was operated upon by Dr. Tiffany, in Baltimore. His object 
was to make a flap out of the scrotum. 



O0I4. 4*so0ssi 



Henry Pickett, Aged Five Year*. 

Has had a swelling on the lower jaw for about three weeks. 
His mother thinks he has a decayed tooth, but has not com- 
plained of the tooth-ache. 

Very often in children we find that where there are diseased 
fangs of a tooth, or where the alveolar processes of the inferior 
or superior maxillary bone are very thin, an irritation is aroused 
which extends along the root of the tooth, and connects itself to 
the periosteum and we have the formation of cold abscesses. 
This boy has a cold abscess, caused by an irritation at the root 
of the tooth, external to the periosteum, in tissues so yielding 
that very little pain is experienced. It is not yet time to do 
any thing with this abscess. The suppuration is slow, and has all 
the characteristics of a chronic abscess. There is very little pain, 
but the suppurating process is proceeding. I can detect slight 
fluctuation there now, and by introducing a needle perhaps I 
could withdraw the matter ; but that opening would not be suf- 
ficient ; the pus would not be fully discharged, and a second in- 



114 CASK OF DEMENTIA. 

cision would be necessary ; and the desire of the mother is to 
avoid a scar. Therefore, I think that we will leave this as it is 
for several days. Bring him back at the end of a week ; if it has- 
fully suppurated, we will withdraw the pus and leave nothing but 
the puncture. Give the boy three powders per day of cal. carb., 
30th trituration. 



Johanna Reglan, Aged Four Years. 

History of Case. — The child can use her hands, but does not 
know how to feed herself ; does not know how to walk ; has a 
vacant look ; is very quiet. 
Prof. Helmuth : 

Here is a case which does not properly belong to my depart- 
ment. There is no surgical disease here. There is a de- 
ficiency in mental development, of brain structure. There is 
such a lack of brain and nervous pow T er that the child, al- 
though it sees and hears, is not able to accomplish the simple 
act of prehension, and does not even know how to eat. She has 
the use of her hands, but does not understand how to take up 
food and put it in her mouth. In a case like this, nothing but a 
long course of treatment can be expected to do any good. The 
prognosis is extremely unfavorable in every way. The peculiarity 
is this: Here is a healthy woman, with a healthy husband, who 
has had several children that are perfectly well ; yet, without 
any known cause, she is delivered of a child mentally deficient. 
It is not my province to enter into this subject — which is very 
interesting; and I shall refer the patient to Dr. Lillienthal. 

There is nothing more lamentable than such a case as this. 
There is nothing so affecting as to see a case which is almost 
hopeless. That child is but little above an idiot. It can see and 
hear, but cannot comprehend . It seems, however, to be physically 
strong. In cases like this we must give an extremely guarded prog- 
nosis. No doubt there are institutions and courses of treatment, 
existing at the present day, whereby such a condition may be 
relieved. This child cannot talk ; scarcely knows how to swallow, 
and probably would not swallow, if it were not a partially in- 
voluntary act. 



Surgical dUttic of $anuaty 9th, 1875, 



Prof. Helmuth [holding up a probe] : Small as this instrument 
is, and insignificant as it appears to the eye, in the hands 
of surgeons who understand their business, and who have an edu- 
cated touch, it becomes of great diagnostic value. It assists us 
in forming diagnoses, which otherwise might be impossible. It 
will tell ns the direction of a fistula, or the course of a wound ; it 
will tell where a bone is diseased, and what is the condition of the 
tissues about a wound, whether soft or hard. In many other 
ways this little instrument renders such service that it cannot be 
dispensed with by either physician or surgeon. 

The exploring trocar is of great value for diagnosing the con- 
tents of cavities or tumors, and should be in every pocket-case. 



^i^#J($i&i aOisgasfe, 



Philip Bound, Aged Five Years. 

History of Case.—FeM down stairs two months ago ; on 
Christmas day his father hung him up by the feet ; since then he 
has had a great deal of pain, and has not been able to walk. 
Prof. Helmuth : 

The left hip is affected. You will notice that the gluteal fold is 
lost on the affected side. There is a distinct line on one side, bnt 
it is entirely gone on the other ; one side is flattened, and the 
other appears to be bulging. Yon will find, I think, that his legs 
are of different lengths. He has had a great deal of pain since 
Christmas. 

We have had an opportunity during these clinics of seeing hip 
diseases in very many of its stages ; and I am glad to bring this 
child before you that you may see a case in its second stage. 
This case exactly illustrates the point that I wish to bring to 
your notice. I can make a great deal of traction on this leg, 



116 HIP-JOINT DISEASE. 

and pull with a great deal of force, without increasing the suffering; 
you see it diminishes it rather than otherwise. Bear in mind that 
a majority of the children that are affected with hip disease 
are those having robust constitutions. The old-fashioned idea 
that hip disease was a strumous or scrofulous irritation of the 
joint is no longer held. Those who have had the most ex- 
perience in the treatment of these diseases state, as a fact, 
that you can generally trace them — in eight cases out of ten 
— to traumatic origin — to an injury of some kind. This patient 
three months ago, fell down stairs and injured his hip. If he 
had been put immediately to bed, and kept quiet, he would have 
recovered. As it was, the result is entirely different. The boy 
was allowed to run. The parents did not understand the nature 
of the disease; and the child was no doubt complaining, from 
time to time, of the injury. Then came a second injury ; and an 
acute inflammatory action set up between the head of the bone and 
its socket, the small blood blister or bruise that existed at the 
head of the femur became still more inflamed, and the consequence 
is, that we have the second stage of hip disease coming on, 
with a tendency to effusion, which gives him excessive pain 
(which is worse at night), and causes an apparent elongation of 
the limb. Suppuration may follow the inflammatory process ; 
an abscess may form and open on the outside ; and that may be 
followed by caries of the bone. 



Hip- Joint :fri»»ft»»» 

August Sissman, Aged Twelve Years. 
{Continued from page 60, 85. and 105.) 
You recollect how emaciated this boy looked when he first 
came here, how sick he appeared, and how painful it was to move 
him. He had hip disease in the third stage. I put on him a 
Bauer's splint, because it was the least expensive ; and was pre- 
ferable to those secured by plaster, because the latter sometimes 
slip. The object of the extension apparatus is to keep up trac- 
tion sufficient to draw the head of the bone from the cavity, and 
allow the body sufficient motion to enable the patient by 
exercise to keep up the general health. In many cases of hip 
disease the patient is placed in the recumbent posture, and a 
weight is applied to the foot. But during such treatment the 
constitution suffers so much from the confinement, that the ob- 






ANGULAR CURVATURE OF THE SPINE. 117 

jeet we are attempting to accomplish is often thwarted. This 
boy has improved very much under the treatment. He states 
that he has a good appetite ; and you see that the roses 
are coming to his cheeks again. He then had a hectic flush ; 
now he has the tint of health. One of the openings in 
his hip is nearly closed, while the other is getting better. He 
has been taking silicea — 30th. Continue giving him the same 
medicine, and bring him back to-day three weeks. I think that 1 
can say that by May you will have him pretty well cured, 
unless he gets a cold ; 1 mean that the abscesses will heal, and 
the boy will be comparatively comfortable. He will limp a 
little for a considerable time. 

— •^+-» — 

( Continued front page 41.) 
(JVo name given.) 

You will recollect that this child had Potts' disease of the 
spine. She has been under treatment since October 1. We 
think that she is better; she certainly is no worse. Even if 
the child were to grow up with that slight protuberance on her 
back, it would scarcely be noticed. She has been taking cal. 
carb., 30th. Continue it and bring her back in four weeks. 
We shall then see a more visible improvement. 

Prof. Helmuth cpiizzes the class : 

Q. What do you understand by tumor, surgically speaking \ 
A. The term is restricted to an enlargement of part or structure 
caused by some specific morbid growth. 

Q. What are some of the diagnostic differences between an 
innocent and a malignant tumor \ 

INNOCENT. MALIGNANT. 

1 . Harmless with reference to the snr- 1. The tumor is apt to destroy or in- 
rounding structures. volve surrounding structures. 

2. Texture bears some resemblance to 2. Texture differs from the normal 
certain of the surrounding structures. structure of the human body. 

3. Non-liability to return (excepting 3. Great disposition to return, 
recurrent fibroid.) 4. Liability to profuse bleeding. 

4. Absence of hemorrhage. 5. Great tendency to soften. 

5. Little disposition to soften. 6. Great tendency to ulceration. 

6. Not much tendency to ulcerate. 7. Very offensive, ichorous or bloody 

7. Earely accompanied by offensive discharge. 

discharges. 8. Infiltration of the parts on which 

8. Non- infiltration of surrounding they grow, which is often entirely trans- 
structures, formed. 



118 TUMOR A* T D ANKIK1SU QjUiZZEK 

Q. What is the color of tumors? A. They vary with the 
number of blood-vessels contained in them, and also with the 
amount of inflammatory action in the tumor, or in the superim- 
posed tissue. 

Q. What is the color of dsbvusI A. Purple. 

Q. Of fatty tumors ? A. Yellow. 

Q. Fibrous tumors? A. Whitish. 

Q. Cartilaginous tumors ? A. White and glistening. 

Q. What is the consistency of fibrous and scirrhous tumors ? 
A. Hard. 

Q. What of cystic tumors ? A. Soft. 

Q. What is a hypertrophic tumor ? A. Is one which consists of 
an enlargement or increase of the proper tissue of the part; some- 
times having a distinct capsule, and contained in the substance of 
an organ. 

Q. What glands are mostly attacked? A. Especially the 
tonsils and the prostate, meibomian, thyroid, and mammary 
glands. 

"Q. What is the simplest variety? A. Chronic enlargement 
of the tonsils. 

Q. What are fibro-cystic tumors ? A. Those in which cysts 
form in fibrous tumors, either by an accumulation of fluid in the 
insterstices or by local softening with serous effusion. 

Q. What are recurring fibroid tumors, and on what part of the 
body do they grow ? A. They are soft, fragile, lobnlated tumors, 
of fibrous structure, grow on the fingers, within glands, and in 
the jaw in close proximity to the bone. 

Q. How can you distinguish abscess from aneurism ? A. By 
the absence of the thrill, by the fluctuation, and previous history 
of the case. 

Q. Which is the most malignant and fatal variety of cancerous 
growth ? A. The encephaloid cancer. 

Q. What is diffuse aneurism ? A. It is formed by the blood 
escaping from a wound in an artery, into the surrounding cellular 
texture. 

Q. What arteries are most liable to aneurism ? A. The aorta 
and popliteal artery. 

Q. What are the diagnostic signs between an abscess and an 
aneurism ? 

A. From the earliest stage of abscess the tumor is hot, throb- 



FATAL ERROR IN LANCING AN ANEURISM FOR AN ABSCESS. 119 

bing, hard, and incompressible ; in aneurism the tumor is of nat- 
ural temperature, and is soft and fluctuating. 

The skin covering: an abscess is inflamed and discolored ; that 
which covers an aneurism is of natural color, or perhaps paler. 

In abscess the formation of the tumor is much more rapid than 
in aneurism. 

In aneurism the tumor is pulsating ; in abscess it is fluctuating. 

Abscesses which he directly over arteries are lifted up every time 
the blood is driven along under them, and hence they pulsate like 
aneurisms ; but they do not pulsate when small, whereas aneur- 
isms do from the beginning of their growth. Aneurisms are soft 
■at first, and hard afterwards ; whereas abscesses are generally hard 
at first, and finally soft. 

The enlargement in abscess cannot be diminished by pressure ; 
in aneurism the contrary is the case. 



{From Prof. Helmuitis work on Surgery.) 

The following is recorded of Dr. Dease, of Dublin : " He was 
called to see a case, supposed to be one of aneurism by all the 
physicians who had attended it, and, upon careful examination, 
determined it to be a large collection of pus, overlying an artery. 
Taking the responsibility, in spite of the advice of those who con- 
sulted with him, he plunged his knife into the pulsating mass. 
There was a gush of matter, and the patient, who looked a short 
time before upon his case as hopeless, was entirely relieved. 
Much credit was justly the meed of Dr. Dease, and great gratifi- 
cation must he have felt at thus relieving the unfortunate sufferer. 
8ome time after, he was sent for to another case, which, like that 
just mentioned, had been regarded as an aneurism; and, as in 
the other, he decided that it was a collection of pus, and proposed 
relief in the same manner. This being assented to, he penetrated 
the tumor with his knife, when out rushed a torrent of blood, and 
with it the life of the patient. He had erred in his diagnosis. It 
was an aneurism — not an abscess ! Dr. Dease returned to his 
home, and on the nexr morning was found upon the floor of his 
chamber with his throat cut from ear to ear, by his own hand ! " 



^urgwat fttinir of |anuarg 16tl>, 1875. 



Harry Pickard, Aged live Years. 

( Continued from page 113.) 
Prof. Helmuth : 

On the side of this little boy's jaw you will recollect that there 
was a hard substance we thought indicated the formation of a 
cold abscess. There is a great deal of difference in the formation 
of pus, when inflammatory action seems to exist, and when 
there is none that is apparent. In fact, a large accumulation of pus 
can take place in a cavity of the body, and yet its formation be un- 
attended by the usual symptoms which belong to acute inflamma- 
tion; but, on the contrary, the system will be seriously affected 
by the symptoms which indicate constitutional irritation. You 
can have the formation of a large quantity of pus taking place 
in the body, or some occult spot and yet have none of 
those inflammatory symptoms which belong to acute forms of 
suppuration. Instead of having a high degree of inflammatory 
action, we may have a low, broken-down condition of the system 
— irritability, quick pulse, pale face, loss of appetite — and a gen- 
eral condition of the whole body indicating that there is a great 
deal of irritation ; and we may even find hectic fever, resulting 
in regular chills, which may be mistaken, on account of the 
regularity of the paroxysms, for intermittent fever. 

This is a simple case of cold abscess on the side of the cheek. 
There is nothing more difficult to diagnose than a cold abscess — 
that is to say, a chronic abscess — when there is a large quantity of 
matter involved. There are some pressure symptoms in ab- 
scesses, which are of a most perplexing nature. Small as this 
abscess appears, it offers a fruitful subject for a lecture ; but we 
have been over the subject quite fully, and I will only refer to 
the insidious nature of those abscesses which occur in different 
parts of the body — and especially in cavities Avhere the pressure 
symptoms give rise to a great many obscure symptoms. 



George W. Fleming, Aged Thirty Years. 

The patient, who has brought a card of introduction to me, 
states that he has been told that he has some trouble with the 
prostate gland ; has had symptoms of the disease for twelve 
years. After every stool, or the passage of urine, there is a dis- 
charge of a dirty, yellowish-white fluid from the urethra — about 
a thimblefull in quantity. Can remain all day and all night 
without urinating. 

Q. The chief symptom that you have now is the loss of some 
fluid after you pass water. Does that, and its train of symp- 
toms, make you feel badly, and weak at times ? A. I cannot say 
that it makes me feel badly. 

Q. Does it worry your mind? A. No, sir. 

Q. Does it make you feel weak, or give you any pain in the 
loins, or humming in the ear ? A. No. 

Q. You only desire to get rid of it, because of its unpleasant- 
ness ? A. That is the reason ; and because I thought it might 
become worse after a while. 

Q. Have you, in addition to this discharge, a loss of power I 
A. Yes; for the last four or live months. 

Q. Do you have any desire for sexual connection, or does the 
loss of desire and of power go together ( A. I have no desire at 
all now. 

Q. Does this discharge pass from you without any excitements 
A. Yes. 

Taking the age of the patient into consideration, the proba- 
bility is against there being a disease of the prostate gland, unless 
it be some disease of traumatic origin. You do not generally find 
disease of the prostate gland until forty-five or fifty years have 
passed. The enlargement of the prostate is, as Sir Henry 
Thompson says, the common heritage of mankind. Nine-tenths 
of the men (I except women) as they advance to the age of fifty 
or sixty, have more or less enlargement of the prostate gland. I 
do not know whether any of you have ever tried to dissect the 
prostate gland from the bladder; but if you should, you will find 



122 SPERMATORRHEA. 

it very difficult to discover where the prostate begins and where 
the bladder ends. One seems to run directly into the other. 
The prostate seems almost to be a continuation of the bladder. 

There is something else the matter with this gentleman. He 
has not an enlargement of the prostate, but he has, I think, a re- 
laxation of the ejaculatory ducts. These ducts open on each side 
of the verumontanum. I will first examine the rectum. I feel 
the prostate gland distinctly. The better way in such an exam- 
ination is to put the patient on his side, introduce the finger and 
turn the ball of the finger up, because that is the most sensitive 
part. As I pass the finger along, I can feel his prostate gland. 
It is quite soft and flexible, and has not that stony hardness which 
belongs to certain forms of disease. I will now pass a catheter 
into the bladder. In doing this it is important, in the first place, 
that you select a catheter having the proper curve. If the man 
had a prostatic enlargement, this sound would not begin to pass 
the entrance. You would have to take one the arc of whose 
circle was at least an inch longer. The curve would have to be 
greater to carry the end of the instrument over the prostate 
gland ; but finding that the gland is not enlarged, I am quite 
sure that this catheter will enter. You place the patient either 
on his back, or leaning backward against the wall. Have the 
catheter well oiled, or, what is better, inject a small syringe-full 
of warm oil into the urethra. I have, on more than one occasion, 
entered the bladder and relieved men without the introduction of 
an instrument at all — after they had been tunneled half the night 
with an instrument — by simply injecting into the bladder a little 
warm oil. At all events, let the instrument be well oiled ; hold 
it between the finger and thumb of the right hand, the curved 
part downwards ; you can then introduce it in the way I now do 
it; then bring it up, so that the handle of the instrument is paral- 
lel with the abdomen ; then draw the penis up, with one hand on 
the instrument, and depress it between the legs of the patient. 
Do not use any force in the passage of the catheter. A steady, 
mild pressure, applied when the catheter meets an obstruction, 
will generally succeed better than any rough manipulation, be- 
cause there is. no portion of the human body so susceptible to 
spasmodic action as the urethra. If, in treating spasmodic stric- 
you fail to enter the bladder the first time, do not try any more 
that day; because every time an instrument passes along the 



PARALYSIS OF THE EJACELATORY DUCTS. 123 

urethra and touches the part which is irritated, it will cause more 
violent contractions; and by using force to overcome the obstruc- 
tion, you may make a false passage, and necessarily render the 
patient a great deal worse. 

This patient has not an enlargement of the prostate gland, but 
he has a paralysis of the ejaculatory ducts, which open on either 
side of the veru-montanum. \That is the best medicine '. 
At one time there was a great deal of talk about cauter- 
izing, and for this purpose an instrument was used, consisting of a 
catheter with a cylinder at the extremity of the wire, at the bot- 
tom of which cylinder was placed some powdered caustic. You 
then draw this cylinder within the sheath of the instrument, and 
having introduced it into .the urethra, you push forward the 
cylinder, and allow it to come in contact with the floor of the 
urethra. The heat of the body then melts the tallow or po- 
made, and the caustic drops down. This treatment (Lallemand's 
was highly recommended for spermatorrhoea, or for loss of semen. 
I used it a great many times, but I must say, that I never saw the 
first shadow of good come from it, and I believe that is the 
general experience of physicians, if they would speak the truth. 
The treatment gives rise to a great deal of pain. Sometimes, 
when the first burning takes place, there may be an arrest of the 
symptoms, but as a general rule it is not in the end successful. 
But still it is highly recommended. Another method of 
treatment i.- by a pad : and these pads were sold by the quacks 
by thousand.-. There is no di-ease that is discussed in so inany 
vellow-covered books as spermatorrhoea. There is no disease that 
upsets a man's moral faculties more than a loss of semen or virile 
power. This loss of semen, whether from spermatorrhoea or mas- 
turbation, or from other causes — it makes no difference what — 
causes patient to become morbid. Although they do not like to 
own it, they are fearful, and are ready to grasp at any thing that 
appears to offer relief. They become morose, and desire to hide 
their condition from other people. They buy these yellow- 
covered books, which advertise a pad, or somebody's specific ; 
and they shut themselves up in a room and read it, and 
send a dollar to the publisher to procure a pad, or a prescrip- 
tion, but do not tell anybody what they have done. That is 
the course that is followed in nine-tenths of such cases ; and 
nobody is any the wiser. The only way that we can judge of 



124 knlakcjkmknt of the SALIVAIiY <; LANDS. 

the extent to which this business is carried on, is by the fact 
that all the proprietors of these " specifics " grow rich. There 
are ten thousand men not far from here, who have these yellow- 
covered books secreted in a drawer, and a bottle of medicine,, 
or a pad, hidden away where no one can find it — simply because 
they do not want any one to know that they have this trouble. 
No one can estimate the amount of money that goes into the pock- 
ets of these outrageous quacks ; and we can only judge of the 
amount by the fine mansions and equipages they are able to 
support. 

As I have already said, I do not regard the caustic treatment 
as of much value, and I have given it, I think, a fair trial. But 
there are several medicines that will relieve this condition — 
such as phosphorous, phosphoric acid, opium,* and picric acid. 
We will give him picric acid, 3rd — four doses per day ; and 
every night let him sit for five or ten minutes m a basin of cold 
water in which has been dissolved two handfuls of salt. After 
taking the bath the parts are to be thoroughly rubbed. Take the 
medicine for two weeks, and then come back. I have never used 
picric acid, but it has the reputation of having cured some re- 
markable cases. We will give it a trial in this case to see how 
it acts. 






Lizzie Smith, Aged Eighteen Years. 

A Lump on her Throat. — Digestion begins in the mouth, in 
mastication and the admixture of the food with those substances 
which come from *the salivary glands. We have the parotid 
glands, the submaxillary, the sublingual, and the iiitralingual, 
emptying the saliva into the laced cavity. The parotid gland pours 
out three-fourths of all the saliva that we use. This gland some- 
times becomes diseased; and in some instances is affected with 
an enlargement called the mumps. The submaxillary gland 
lies lower down, on the inner side of the inferior maxillary bone. 
All of these glands are under the influence of the nervous system,, 



TREATMENT OF ENLARGEMENT OF THE SALIVARY GLANDS. 125 

and they can pour out into the mouth their secretions bj a 
nervous act. For instance, if, when you were a boy, hungry and 
poor, you gazed into the window of a cake shop, the saliva would 
flow into your mouth; that is what is called "mouth-watering." It 
is by the nervous action on the glands that they are stimulated to 
secretion. These glands, which secrete the salivia, sometimes en- 
large. There are other diseases which are specific in their char- 
acter which I w T ill not now describe. An enlargement of the 
salivary glands, with a tendency to suppuration, can be entirely 
cured by the use of mercury. I hope that this will not suppurate, 
although it now presents many inflammatory symptoms. When 
you have a salivary gland which is enlarged and hard, and there 
is an increase in the flow of saliva, then, of course, mercurius is 
the medicine, because mercurius, taken by a healthy person, will 
cause an enlargement of the glands and increase the flow of 
saliva. In other cases, where there is an enlargement, but no 
increased flow of saliva, belladonna is the remedy. Other medi- 
cines are baryta, carb., conium., sulph. etc. 



Jjfotgual eiims of gamtary 23 wl, 1875. 



Prof. Helmuth being called suddenly to Stamford, Dr. Thomp- 
son, after reading a letter explaining the absence of the Pro- 
fessor, conducted the Clinic. 



Ltjcy Francis, Aged Five Years. 

Dr. J. H. Thompson : 

This is a case sent by Prof. S. P. Burdick. In July last she fell 
down and broke her arm at the elbow. It has been broken three 
times, and the elbow-joint is quite stiff. The second breaking of 
the arm was done by a physician, because it had been improperly set. 
This is the first that I have seen of the case. The physician put 
splints on, and kept them on for three weeks. When the splints 
were taken off he could not move the arm. Three weeks is an 
uncommonly short time for an arm to become stiff in a child ; but 
it is not too long to keep the splints on, in ordinary cases. The 
only way that I can account for this arm becoming stiff in that 
time, is by assuming that there might have been a fracture of the 
condyle, and an effusion thrown out ; in that case it might have 
become anchylosed in that time. I think that you could get some 
movement in this joint, if passive motion was persisted in. It 
would be well to put the patient under the influence of an anaes- 
thetic, and have those adhesions broken up. Unless this is done 
soon, she will have a stiff arm as long as she lives. Passive mo- 
tion is the only manner of cure and of preserving the joint, after 
a fracture at, or near the joint ; and it must be persisted in perse- 
veringly, but without using too much force. If you use too much 
violence in producing this passive motion, you do a great deal more 
harm than good. Therefore, to be beneficial, it must be persisted 



ENCYSTED TUMOR. 127 

in for a long time, but not to such an extent as to throw the 
patient into a fever each time, as was done in this case. You will 
remember the case of the little boy, at the first Clinic of this 
season, whose arm was fractured at the external condyle. He 
came to my office a great many times after that, and I made pas- 
sive motion with the ,arm with the utmost care ; but I have not suc- 
ceeded in getting a perfect motion of the joint, and the motion is 
still somewhat impeded. So you will observe that it is not always 
a means of perfect restoration, even when properly attended to. 
In this case, perhaps, the passive motion was carried to too great 
an extent, and stiffness of the muscle, instead of flexibility, was 
the result. But the only chance of obtaining a movable joint is 
to place the patient under the influence of ether, break up these 
adhesions, and then carefully persist in passive motion for three 
or four weeks. 



Timothy Darly, Aged Forty-two Years. 

History of Case. — The patient states tha the has had this on his 
back for about twenty years ; has another smaller one near it which 
has been there for twenty-five years. The large one was lanced 
about a year ago and then healed up. It did not trouble the pa- 
tient much until then. It broke this morning. Before it broke 
it was smooth and round. 

Dr. J. H. Thompson : 

This is an encysted tumor. They will sometimes remain with- 
out much increase in size or occasioning inconvenience for a long 
time. About a year ago suppurative action set up in this tumor, 
and pus probably found its way to the surface, just within 
the membrane of the sac, under the skin. It was then lanced, 
and soon afterwards healed up. Since that time, suppuration has 
a^ain taken place ; and this morning the tissues became so thin 
that the sac ruptured. As I squeeze it you see all the contents 
of the tumor gush out. There is some pus mixed with it. The 
suppuration has probably destroyed the sac, and we will apply 



128 HYDROCELE — ABSCESS — VARICOSE [JLCBR. 

strips of adhesive plaster, and I think very likely that adhesion 
may take place, and a spontaneous cure result without any opera- 
tive interference. 



£ 



ttyftrooelo 



George Campion, Aged Fifty-two Years. 

This is a hydrocele. I saw this patient in the dispensary on 
Tuesday, and requested him to come to my house that night, when 
I injected the compound tincture of iodine into the sac, without 
drawing off any of the serum. About two hours after I had done 
this, there was considerable inflammation set up, which continued 
until last night. On Thursday he called again to see me. The 
treatment which I adopted is a new one. The case is going on now 
very well, and I shall not do any thing further. I simply brought 
him here to-day to show you the result of the treatment. 



&W**&j$: 



Henry Turnherr, Aged Tiventy -eight Years. 

An abscess is forming in the lower jaw. The patient states that 
it resulted from a blow. Let it be poulticed every three hours, 
and let the patient return on Tuesday. 



¥**£**•+ OT#^ 



Mary Kegan, Aged Thirty-two Years. 

I have brought this case to show you a varicose ulcer. This 
patient is a washerwoman, and stands on her feet a great deal. 
Varicose ulcers are frequent with such people. The blood passes 
down the limbs, the coats of the veins become dilated, so that 
the valves cannot perform their functions properly, the blood 
does not return freely, and you have congestion. Here you see 



HYPERTROPHY OF NOSE^ 129 

the varicose veins. The foot is very much enlarged. The circu- 
lation becomes impeded, and finally an ulcer forms. She has 
been in this condition for twelve or fifteen years ; she has had 
this open sore for nine or ten years. It has occasionally healed 
up to within about a pin's head, and then it would break out 
again ; as the inflammation increased, the sore would gradually 
extend, until it finally got into the condition in which you now 
see it. By keeping her foot upon a chair for a while, and stop- 
ping work, it would partly heal up. The pain is always worse 
at night. 

The best treatment for this, in the first place, is rest ; but, as 
this disease generally appears in persons who cannot rest, it 
continues until it assumes the form you now see. If this 
patient could go to bed and keep the horizontal position for two 
or three months, this leg would get well. The palliative treat- 
ment, which is almost the only one you can use in this case, is to 
bandage the leg, or apply an elastic stocking. The elastic stock- 
ing is very valuable in such cases, as it keeps up a constant pres- 
sure on the foot or leg. It must be tighter below than it is 
above ; because, if you have it tight above and loose below, you will 
have a worse constriction than with the leg unbandaged. The 
radical cure is effected by the destruction of the vein with caustic 
potash or acupressure. I would recommend the patient, besides 
bandaging the limb, to apply to the sore an ointment, composed 
of Red Precipitate of Mercury, 1 drachm ; Simple Cerate, 1 ounce. 
Spread on a piece of linen. Dress the limb twice a day. By 
this treatment she can continue her occupation, and the limb may 
become very much improved. 



Mary G-aas, Aged Thirty-six Years. 

This patient has an ulcerated condition of the palatine portion 
of the mouth, in addition to lipoma of the nose. Lipoma comes in 
two forms — flattened and pedunculated. When pedunculated, it 
sometimes hangs down on the face to an extent of several inches. 
It occurs more frequently in man than in woman ; and generally 



130 PERIOSTITIS. 

in men who are over fifty years of age, and who have been ad- 
dicted to high living, or to the use of alcoholic beverages. I do 
not know of any remedy that can be given internally that will 
have much effect upon this disease. The knife is the only resort,, 
and that is better resorted to in cases where the lipoma is pedun- 
culated than where it is flattened. This disease never interferes 
with the mucous structure or with the cartilage of the nose. 
Although it is with a great deal of difficulty that it can be 
removed, yet with care it can be done. I shall not undertake to 
operate upon this case to-day, because there is so much surface 
involved that I am afraid that we should not find material 
enough to make the flaps to cover the gap. If there 
should be any thing specific in the case, of which we have some 
indication in the pharynx, we should have a more unhappy result 
than if we left it in its present condition. It has been recom- 
mended by some that iodine should be employed locally ; and 
I will use it in this case. But, instead of applying the tinc- 
ture of iodine, which would give her a great deal of pain, I 
will prescribe an ointment of the iodide of potash. The prescrip- 
tion is thus written : 

"I^ : Ung. Potas. lod. §ij-" 
Spread the ointment on a piece of linen and apply it to the 
nose. 



2p#¥i<»at&1£ji: 



Bridget Doyle, jLged Tvjenty-three Years. 

History of Case. — A felon on the end of the index finger of left 
hand. Has been sore three weeks. Does not remember bruising 
it in any way. She poulticed it for a while, and then opened it 
with a needle. It then became worse, and she went to a doctor, 
and had it opened with a knife, but not very deep. 

Dr. Thompson: 

This, as you know, is a form of felon — the fourth variety in 
which the pus forms under the periosteum; and in this case the 
bone has become diseased. In treating this disease where the 



PARALYSIS OF THE (ESOPHAGUS. 131 

inflammation has affected the deep tissues, and there has been an 
effasion of pns under the periosteum, slight incisions do more 
harm than good. You must go down into and through the peri- 
osteum, to allow of the evacuation of pus underneath; for 
that is the cause of all the trouble. If you prick it lightly 
through the skin, you may perhaps find a little pus, which has 
formed under that tissue, but the discharge of that will give 
relief for only a few hours. If you wish to do the patient a real 
service and give permanent relief, you must cut down until you 
feel the bone with the point of the knife. If the patient had 
gone to a doctor in time, and had the finger thus opened, I have 
no doubt she would have saved the bone, which I now feel with 
the probe and easily remove. The end of the finger should be 
tightly bandaged every day, and the openings will soon heal. 






Sidney Fanning, Aged Fifty-Jive Years. 

The patient states : I was sent here by Dr. Kushmore, of 
Hempstead. My trouble is in my throat, above the entrance to 
the wind-pipe. It has been coming on for a year or more ; but 
more rapidly within the last four or six months. I have very 
great pain in swallowing, and frequent coughing. Dr. Rushmore 
said that it was an obscure case, and sent me here to find out 
what was the matter. After talking a little while, it hurts me. 
In eating, if I use soft food, the most of it will pass down. If 
I use hard foods it will remain in the throat. I make every effort 
to swallow, but it remains, and I can eject it, as I would phlegm. 
It seems sometimes almost impossible for me to swallow any 
hard food. I can exercise but very little. I gave out twice in 
coming up these stairs. The pain is only in the act of swallow- 
ing. I have no difficulty in breathing. At times it is very 
difficult for me to make any effort to swallow ; and I will go for 
hours without even swallowing spittle. I can drink warm fluids, 
if they are not too warm, better than cold. 



132 ABSCESS. 

Dr. Thompson : 

I will refer this case to Dr. Houghton who will examine his 
throat with a laryngoscope. 



John Thomas, Aged Twenty-three Year*. 

Dr. J. H. Thompson : 

This patient was sent to my house on Thursday by Dr. 
Norton, suffering with an abscess just back of the anus. 
The skin over it was very thin, indeed, and I opened it and 
evacuated a large quantity of pus. I told him to poultice it, 
and he has done so, and took the poultice off this morning. This 
may be the beginning of a fistula. It was a very large abscess 
when I opened it. It does not hurt him at all now. I gave him 
Silicea, 30th trituration, internally, three times a day. He need 
not poultice it any more, but may continue the use of the silicea 
for a short time longer. 



j^wjical €\mk of famtaty 30th, 1875. 



Miss Yan Houghton. 

{Continued from page 55.) 
Prof. Helmuth : 

Gentlemen: You recollect I presented to yon a case of cleft pal- 
ate early in the session, and yon remember I stated at the time, 
that this class of cases was hardly the variety to operate upon 
before yon, because it would be impossible for you to see the 
steps of the operation, which is always tedious. This patient 
was therefore removed to the surgical hospital, and the opera- 
tion was performed with instruments with long handles, such 
as you see here. This was the operation : I pared the edges of 
the fissure ; Dr. Thompson put in the stitches, and Dr. Cranch 
took them out. It is always proper and necessary that you have 
instruments with long handles, and particularly that the knives 
shall have long shanks, and a short cutting edge. You should 
also have blades bent at right angles, to loosen the tissue 
from the palatine bones, and also a double-edged knife to insert 
under the edge of the palate, to divide the levator palati, in 
order that the flaps may fall together after you have pared them. 
Then you have scissors, with handles such as you see here, 
and a long needle-holder. The needles you use are the same 
as those for vesico vaginal fistula, sharp and round, with no 
cutting edge. They should be threaded with silk, and the wire 
hooked into that. Here is one of them, round, and curved at the 
end. If you have a long needle, it is almost impossible to 
draw it through one lip of the cleft, before you introduce it 
into the other. Now, holding the needle at an angle, you 
introduce it on one side about a quarter of an inch from 
the margin, and you push it through and catch it inside the 
cleft, draw it out, and draw the silk through. Then enter it on 
the other side, directly opposite, and draw it through. It is better 
to put in two or three stitches at once, before you draw them 



134 PHLBBOLITHBS. 

together. If the case is a very severe one, as now shown you, 
you will have to perform two, and perhaps three operations. So 
far, this has been a successful operation, and, as you see, I prefer 
to bring in the patient after its performance, that you may observe 
for yourselves, rather than to keep you sitting in the amphi- 
theatre while the operation is going on. This would be tedious, 
you could see nothing and could learn nothing. [To the patient : 
Open your mouth.] You can seethe cleft is almost closed. There 
still remains an opening at the roof of the mouth. [The surgeon 
introduces a spatula into the patient's mouth.] Now you can view 
it very well, by looking at the roof of the mouth when the patient 
holds the head up. It is very nicely united, indeed. You observe 
the fissure is all closed except a little slit in the upper part of the 
mouth. The next operation for me to perform will be to close 
the top of the fissure, and, I hope, the effort will be success- 
ful. The stitches were allowed to remain five days before they 
were taken out. 



MlU^tiMft 



Prof. Helmuts:: 

I will now introduce to you Mr. Howell, who appears before 
you out of regard for the class, to show you a very peculiar and 
aggravated case ? of varicose veins of the right fore-arm. 

Q. Whatisvarix? A. Preternatural enlargement of the veins. 

History of the Case by the Patient. 

This condition was discovered when I was about a year old. It 
didn't bother me any. I had the full use of my arm. 
Prof. Helmuth: 

Q. This is a true case of varicose veins. , These have existed 
since birth, have they not ? A. Yes, sir. The arm was examined 
by Prof. Parker, of the Old School, when 1 was about 7, 8, or 9 
years old. I could not stand the pressure he recommended. 

Q. You never had any hemorrhage from them ? A. ~No, sir. 

Q. Do they give you much pain ? A. No ; unless I am unwell ; 
then I feel pain. What I want to call your attention to is, you 
will feel all the way down the arms hard, bony deposits. 



PHLEBOLITHES. 135 

By Prof. Helmuth: 

This is a peculiar condition of the veins. After they have 
become diseased for some time, and their coats seem to have be- 
come enlarged, a deposit takes place within them. These con- 
cretions are first cartilaginous, but finally an ossific deposit 
takes place in the coats of the vessels. By taking hold of 
the arm and pressing upon the larger veins, in the neighborhood 
of the valves, here and there, you can feel quite distinctly the 
presence of the foreign substance, which really seems to be bony. 
In some places it is cartilaginous certainly. Nature is trying to 
cure the disease. Now, this is simply an illustration of how long 
a disease may continue and the patient not be obliged to be 
confined, and also how a formation may exist in the veins 
themselves, and yet no manifest change be shown from the ob- 
struction of the circulation. 

Q. Do you have any numbness in that part ? A. No, sir. 

Q. Does it hurt you ? [Prof. Helmuth presses on the veins.] 
A. Yes, sir ; now it does. 

Q. It doesn't interfere with your general health I A. No, not 
at all ; and the more exercise I have the better it is. 

Q. You have given up treatment? A. I don't do anything, ex- 
cept I bathe it almost invariably in the morning with cold water. I 
have had a good deal of experience with it. I used to carry my 
arm up, but I noticed it would grow weaker ; and when I would 
lay it down a little, it would instantly pain me. Now I hold it 
hanging down, and never have any pain. 

Q. Do you find the condition increases ? A. No ; I don't 
think it does. 

Q. I have no doubt those veins will be obliterated if your 
health continues good. The valves will be shut down, and there 
will be ossific deposit. The outside ones may rupture, you may 
have severe hemorrhage, and, as I say, the veins will then become 
obliterated. This is a trial on the part of Nature to do away 
with this condition, and she is endeavoring to place obstacles 
that will obstruct the circulation, and she is doing it now. 

Q. Do you find these deposits grow 1 A. Yes; they are grow- 
ing — some of them I can feel increasing in size every day. 

This is a very rare case, and I am very much obliged to the 
gentleman for offering us the opportunity of inspecting it. In 
the ordinary treatment of varix there are a great many methods 



136 CASE OF ONYCHIA MALIGNA. 

employed for the relief of the enlargement. By the application of 
caustic lime and soda, an eschar is produced. Another method is 
the passage of two pins underneath the veins, winding over them 
a silk suture to obstruct the circulation, then introducing a teno- 
tome, and dividing the veins between the pins. For instance, we 
have veins that are tortuous. We introduce a pin underneath 
the vein and bring it out there, and (illustrating on black-board) 
another pin there. Then we twist over the pins a figure 8 
suture of silk ; then pass the tenotome underneath the veins flat- 
ways, turn up the edge, and cut it through. This is one of the 
very best methods of obliteration. 

The Patient : Do you think there is more than one vein im- 
plicated here ? 

Prof. Helmuts: : Oh, yes ; I think all the superficial veins of 
the fore-arm are involved. 



¥m. Brown, Aged Five Years. 

Prof. Helmuts: 

Here is a patient who has disease of the toe-nail which has 
become inverted. The nail is dead, and it will be necessary to re- 
move it, and I will now proceed to do so. The patient is a little 
boy. Put him on the bed ; let his foot hang down over the end, 
that we may see the condition of the nail. It is dead, putrid — 
black ; but still it lies in the matrix, and there yet remains enough 
connection between the dead and living structure, to keep up a 
certain amount of unhealthy growth. The nail must be removed 
at its root. This is a different affection from the ordinary in- 
growing toe-nail ; in the one case the nail grows in and obstructs 
the circulation, and we have ulceration as from a foreign body. 
In this case, however, the disease is at the root of the nail itself. 
You see it smells like a piece of dead bone, and must be re- 
moved as soon as possible ; and we will therefore spray it with 
ether and produce local anaesthesia. Before the introduction of 
local anaesthesia, we often used to freeze portions of the body be- 
fore operating upon them, and in this way I have removed many 
tumors. The preparation principally used in those days was ice and 



ONYCHIA MALIGNA. 137 

salt. Then came ether, and then local anaesthesia, as it is now 
used for many surgical operations, such as lancing a felon, the re- 
moval of small tumors, portions of toe-nail, etc. But there is a 
substance which readily chills the tissue to insensibility, and 
that is Rhigolene, introduced by Henry J. Bigelow, M. D., of 
Boston. It takes about three minutes to freeze the parts. [ Prof. 
Helmuth extracts the nail.] You see that, although the top of 
the nail was in a very diseased condition, still at its root it was 
quite healthy, there being sufficient action going on from the 
matrix to keep up a certain amount of healthy nutrition. The re- 
moval of nails is very painful, and the trouble arising afterwards 
is, that there is a tendency to the formation of unhealthy granu- 
lations, which ultimately result in a fungous growth. I will first 
stop the hemorrhage by pressure, as there will be considerable. I 
will then apply a plaster of oxide of zinc ; watch the parts very 
closely, and, if the granulations seem to be unhealthy, we will give 
nitric acid internally, and apply a solution to the parts. 

Let me explain to you a little how these nails grow. 

You all know that we have the skin divided into two layers, the 
cutis vera, or the true skin, being the inferior layer. It is com- 
posed of two layers, the corium and papillary body, and over 
the papillae lies the basement membrane, and then the epiderma. 
The office of the former is to generate cells, which, as they 
come to the surface, become scales and are cast off. The epidermis 
and the corium are reflected back on each finger, as you see there, 
and a groove is formed and the papillary body comes up to the 
groove. From the papillary body we have the basement mem- 
brane, and new cells are formed from the basement membrane, 
and this constitutes the matrix of the nail. The cell is formed in 
the groove of the epiderma, and the nail grows out as you see 
there. Now, in removing the toe-nail, you seize it with forceps and 
withdraw it by force ; but sometimes the granulations are so un- 
healthy, and there seems to be so much constitutional irritation, and 
the parts have become so exceedingly sensitive, that you have to 
use not only local, but general anaesthesia. Often in very aggravated 
cases of ingrowing toe-nail, you can cure your patient by taking 
a knife, holding it as if you were about to whittle, and, shaving off 
the tissues straight down to the nail, letting the nail remain as it is. 
Another excellent method is to scrape the nail on the top until 
it becomes sensitive, cut a notch into the centre of the apex of it, 



138 RUPTURE OF THE CORAOO CLAVKTLAK LIGAMENT 

and elevate each side by tucking under it lead, such as you will 
hnd in tea boxes. Another method was contrived by a dentist, and 
is one not generally known. He simply bent a little piece of sil- 
ver wire into a curved shape, and turned in each end like a hook. 
He raised up the ends of the nail and hooked the ends of this 
spring under them, and the constant traction of the spring had a 
tendency to raise the nail from the sides and let it grow out. It 
is a very nice method, and you can make the instrument yourself. 
A little piece of watch-spring will answer the same purpose. You 
•can cover it with a piece of thread. It is astonishing how little 
pressure it takes to cause a nail to grow in the right direction. ■ 



lay X4ga*»e«rt &*»<A 3*i*i*e4 

William Spelman, Aged Sixty -eight Years. 

Q. Where were you born ? A. Philadelphia. 

Q. Blackberry alley ? A. No, sir ; at the corner of Sixth 
and Lombard streets. 

Q. I was your neighbor. Did you know Doctors Helmuth and 
Sims ? You have come to the right place at last ? A. I cannot 
raise this arm. 

Q. [To the Students.] Are any of you, gentlemen, prepared 
to diagnose this case — you who are looking for those glossy 
sheepskins? We have been lecturing a good deal of late on shoul- 
der affections, and this will be quite interesting. 

Q. [To the Patient.] Now tell me about your trouble. Stand 
face to face. Does that hurt you (moving arm upward) ? A. It 
pains. 

Q. Where does it pain you ? A. Under my shoulder. 

Q. Stand straight — put your elbow on your chest — now put 
your hand up here (on opposite shoulder). He has now his elbow 
down to his chest and his hand on the opposite side. Now we 
will see what else is the matter. I will examine his shoulders 
from behind. There is a little difference in their contour, the un- 
injured one being a little higher. Put your hand behind you — 



AND BRUISED CAPSULAR LIGAMENT. 139 

tlie affected hand. Bend it at the elbow. Bend it up this way (to 
a right angle). Does it hurt you any ? A. Yes. 

Q. Where does it hurt you ? A. There (at the joint). 

Q. Now, put it forward again. Now, put your hand up to the 
top of your head. A. I cannot do that. 

Q. Let me see how high you can raise it. A. This won't let 
me get it up (putting his hand to acromion). 

Q. What won't % A. The pain there. 

Q. Does it hurt you very much ? A. It does. 

Q. Right where I have my fingers, all around the head of that 
bone ? A. Yes. 

Q. You may turn around ; does it hurt you there, too \ A. 
Yes, sir, very much. 

Q. Now, tell me how you fell ? A. My foot slipped. 

Q. Then, did you fall \ A. Right down on my shoulder. 

Q. But you can't get your hand to your head ? A. No, sir. 
It is not broken, but it is bruised, and I want to know what lean 
do for it. 

Q. We have looked for these three things. First, we have got rid 
of the dislocation into the axilla, but he cannot raise his hand to 
the top of his head, and he cannot put his hand in this direction, 
(upward), but can put it so (downward). He has all the muscular 
actions of his fore-arm. I cannot find that he has any fracture, 
but he has certainly bruised the capsular ligament, and it will be a 
long time before he recovers ; and at the same time he has also 
ruptured the ligament that holds the clavicle on the top of the 
shoulder joint ; that is quite evident; you can feel the end of the 
bone under the finger. [To the patient.] You will get over this, 
but it will take a long time. A. That is what I think myself. 

Q. Then you agree with me in my diagnosis { A. Yes, sir ! 

Q. That is all right. The best remedy is to keep the arm well 
supported at the elbow witli a sling, and to hold it across the 
chest in that manner. Bathe the parts thoroughly with a solution 
of arnica and water. Let it rest. We will have a sling made for 
you, and it will get along. You will have to hold your elbow 
right up so. Come and see us in about two weeks. I presume 
this is your first introduction to the medical profession ? A. I have 
never had a doctor before. 

Prof. Helmuth : That is the reason why you have lived so long. 

Q. [To the Students.] What is the difference between this 



140 CASE OF MOVAHLK ( 'AKTFLAGE. 

injury and fracture of the surgical neck of the humerus ? A. If it 
were a fracture, raising the arm at the shoulder would restore 
shape to the parts. 

Q. When you push up the head of the hone from the elbow, in 
fracture of the humerus, and let go of it, how would it be ; would 
it remain there, or drop down ? A. Drop down. 

Q. In fracture of the surgical neck of the humerus, then, how 
would a patient look when he came for treatment ; how would 
the shoulder be, when you looked at him from behind ? A. The 
shoulder would be dropped like that. 

Q. This man has very little dropping of the shoulder. In the 
fracture of the surgical neck of the humerus, the affected shoulder 

is flattened ? 

, .*» 



Mr. Fisk, Aged Forty Years. 

Q. Can you give us a little history of this trouble ? A. The 
first symptom I noticed was quite a sudden pain in the knee,, 
like a bruise, which for three or four weeks troubled me very 
much. I looked at my knee, but could see nothing — no bruising, 
or any thing of that kind. I then examined underneath to the 
right, and between the cords I found a lump about the size of a 
walnut, and it has grown larger until it has grown to be about half 
the size of an egg. I used to bandage it, for it goes back some- 
times, and cannot be felt, but it pains me. 

Q. What is your business ? A. A carpenter. 

Q. Are you on your feet a great deal ? A. Yes, sir. 

Q. Did you sprain that knee or fall down. A. No, sir ; never 
to my knowledge. 

Q. Let us see it. [Prof. Helmuth examines the popliteal 
space.] Does this ever give you any sudden pain ? A. I will 
sit down to my dinner, get up, and be lame from it, and have to 
limp. [Patient gets on the table.] 

Q. Does it disappear on pressure ? A. Below there, it does 
sometimes. 

Q. We will now compare legs. Can you get the tumor out 
when you want to ? A. It will come out when I come down on 
my feet (getting off the table). 






MOVABLE CARTILAGE. 141 

Q. Does the pain come suddenly ? A. No, sir. 

Q. Does it catch you % A. No, sir. 

Q. It is hard to the touch ? A. No, sir; soft. 

Q. Judging from the character of this disease, and from the 
manner this tumor appears and disappears, the sudden character 
of the pain, and the stiffness of the joint when he attempts 
to move, I should say, perhaps, there is a loose cartilage within 
the joint. There are in the cavity of the joints, and more es- 
pecially ' in the knee-joint, movable cartilages, which wander 
from place to place. They seem to originate from the synovial 
membrane by the side of the joint, and are generally attached 
to it by a pedicle until some motion of the patient has a 
tendency to loosen them, and then they move within 
the joint. There is a good deal of surface between several 
bones which enter into the formation of the knee, and a car- 
tilage of no very ordinary size — even that of a marble — will move 
■about from place to place, and give rise to little inconvenience 
except when it comes between the condyles of the femur 
and the head of the tibia, and pressure is made on it; then the 
pain is sudden, and the patient even sinks down. The peculiarity 
of these cartilages, when you come to examine them, is simply this : 
They bear a close resemblance to healthy cartilage, and perhaps 
the same relation as the sesamoid bones to the bony portions 
of the body. They seem to be developed in the joint and grow 
from the synovial membranes. They are pedunculated at first, 
and afterwards become loose, and fall in the cavity of the joint. 
There are several methods which have been recommended for the 
relief of this affection, and I know one case which was cured en- 
tirely, or said to be, by the internal use of rhus. I also gave rhus 
to a member of the class, a patient, but I don't know that it pro- 
duced much effect. I know, however, of a patient that was cured 
through internal administration of medicine. If drugs do not 
effect a cure, the removal of the offending substance may be 
effected, by having a strong iron ring made to press down over the 
cartilage, and making an incision through the diameter of the ring, 
at the same time pressing on the parts and allowing the foreign 
substance to pop out ; the object being chiefly to prevent air from 
entering the joint. We will therefore prescribe for this patient 
for the present. 



142 HIP-JOINT DISEASE. 

[To the Patient.] I would like to see you back here in a couple 
of weeks. 

Q. When walking with apparent ease, do you have a sudden 
pain in the joint? A. A sudden, sharp, sticking pain ; a stitch. 

Q. But you can move about without much pain ? A. Yes, sir. 

Q. When you are walking without pain, does this catch you 
suddenly? A. Yes, sir. 

Q. That is the character of these affections. The patient may 
be walking without pain, and all at once the cartilage falls in be- 
tween the two portions of the articulation, and the pain is excru- 
ciating, the offending material being caught between the bones. 



August Sissman, Aged Tioelve Years. 
{Continued from pages 60, 85, 105, and 116.) 
Prof. Helmuts: 

Q. This is the boy that was wearing the splint. I see [to the boy's 
father] you have bought him a new pair of shoes. How is he now ? 
A. He is pretty good. I bought them because it was bad weather. 
They are a little larger than the other ones. He has more room 
in them, and he steps out pretty well. 

Q. How are the discharges from his hip ? A. Very much 
better; they come out a great deal less. 

Q. Are the discharges less than when you first came ? A. Yes,, 
sir. 

Q. And he don't have any pain at all? A. No, sir. 

Q. His foot now comes down very near to the ground? A. 
Yes, sir. 

Q. Let him walk a little. He steps on it very well, indeed. 
Do you keep that screwed up (pointing to the bar of the splint)? 
A. Yes, sir. 

Q. Do you take it off at night? A. Yes, sir ; in the evening. 

Q. [To the Boy.] How do you feel; pretty well? A. Yes, sir. 

Q. Aren't you glad you came here? A. Yes, sir; I am. 

Q. What medicine is this boy taking ? A. Calcarea. 

Q. What day did you come here first ? A. On November 7th. 

In the course of six months this boy I hope will be well, although 
the leg will always be a little short. But you recollect how he 
looked the first time. Now he is nearly well. 



PARTIAL PARALYSIS OF THE OESOPHAGUS . 143 

[Parent.] He goes out every day a couple of hours to stretch 
his leg ; for exercise. 

Continue with the medicine. I desire you to bring him here 
once more, about the last of February, and then we don't want to 
see him again until next October. I want you to bring him then, 
as I think by that time he will be nearly cured, and I wish to have 
him appear before the class. 

[To the Students.] One reason that this patient has done so well 
is because his parents have taken such an interest in his case. 
In nine, out of every ten such cases, no benefit results, because the 
treatment is so tedious, and requires such constant watching, that 
even parents themselves, become negligent in the bestowal of 
proper attention, such as looking after the splint, giving the limb 
the requisite amount of rubbing, etc. 



SPur^i^l Pavatysia 0IIH0 CCaey %*> 



Sidney Fanning, Aged Fifty-five Fears. 
{Continued from page 131.) 

[The patient examined with a Laryngoscope.] 

Prof. Helmuth: 

This patient will explain his case to you very well, therefore 
I think I will allow him to tell his story. 

The Patient : I judge from the remarks of one of the pro- 
fessors of practice that mine is a case of inflammation of the 
larynx, and was of such a character, as I understood the doctor 
to describe Laryngitis Carcinomatous. I forgot the name for 
three or four days, and was thinking of the word cosmo, but knew 
that was not it, but I got it afterwards. 

Q. What did you say it was ? A. Laryngitis Carcinomatous. 

Q. What else was there about it ? A. Professor Houghton said 
it was inflammation of the epiglottis as thick as my finger ; all 
the cartilages were enlarged on account of the inflammation. 
[A student, who was present at the laryngoscopic examination, 
corrects the patient, and explains the nature of the disease.] 

Q. You say there was inflammation all around the perichon- 
drium 1 A. Yes, sir. 



144 PARTIAL PARALYSIS OF THE (ESOPHAGUS. 

Q. Down to the vocal cord ? A. He could not see them 
very well, but the epiglottis was pressed back and very thick — as 
thick as my finger. 

Q. How long has this been going on ; did the doctor prescribe 
for you? A. He did. 

Q. Did you know what he did ? A. I could not say. 

Q. JSTow we will find out what the symptoms are. Can you 
tell us when this trouble first began ? A. Ten years ago. 

Q. You seem to speak better now than when you first came 
in ; how did it appear first ? A. As a hacking at different times. 
When in church, after singing one or two verses, I always had to 
go out, and would go this way [coughing]. I remember of that 
15 years ago. 

Q. Did you become suddenly hoarse ; and would you be worse 
towards evening ? A. I don't remember. 

Q. Did you have any dryness in your throat, in the morning 
especially V A. I think I did. 

Q. Did you ever lose your voice entirely ? A. No, sir. 

Q. Does it hurt you to swallow ? A. Very much ; liquids, or 
any thing cold, or any thing approaching solids. 

Q. Suppose you were to take a warm semi-solid, like milk toast, 
could you swallow that % A. After swallowing a small portion, 
and trying a little, then I could gradually swallow soft milk 
toast. 

Q. Do you ever, after swallowing any thing, regurgitate it ? 
A. Not immediately after swallowing. I can swallow part. The 
other part will remain, and I try to swallow it. 

Q. You only get part down ? A. Yes, sir. 

Q. Do you ever choke when you swallow, and have the fluid 
come out of your nose ? A. Very often ; within the last three 
or four months that has been the trouble with me. Three 
months ago I could eat pretty well, but gradually after my 
meals, in attempting to ^wallow a mouthful of food, part would 
come through my nostrils, and part go into my wind-pipe, and I 
would be choked. 

Q. That is just the bother ? A. Yes, sir. 

Q. [To the Students.] This man has partial paralysis of the 
superior muscle of the pharynx, and besides that inflammation 
of the perichondrium. 



SUBACUTE THECITIS. 145 

Q. Are you growing worse? A. Yes; gradually growing 
worse. 

Q. How old are you ? A. Fifty-five. 

Q. And you have enjoyed tolerably good health ? A. Yes, sir. 

Q. Did you, in your younger days, bolt your food ; do you now 
eat in a hurry ? A. Most generally, like men in business. 

Q. Yery hot and cold things make no difference to you ? A. 
No, sir. I swallow them all alike. 

Q. And then you run off to work with your mouth full? 
A. Yes, sir. 

(To the students.) This is a trouble which may result, sooner 
or later, in a stricture. He has partial paralysis of the superior 
muscle of the pharynx, which don't act, or at least does so 
only partially. He takes a drink, or a sup of fluid, and he gets 
half through swallowing, and the action stops. You have all 
noticed how the oesophagus contracts in the horse when drink- 
ing water, and so it does here. These different fibres of the mus- 
cles act consecutively one after the other, and being under control 
of the will, all goes well, but if one set of fibres does not act in 
unison with the others, we have a reverse action, and part of the 
food is ejected, and only part goes the right way. I should suppose 
electricity would be a good thing to be applied here to the neck, 
and I would also administer cocculus. I forgot you have been 
prescribed for ; therefore you will go on and take the medicines 
ordered. 

(The patient.) I am through with that prescription to-day. 

Q. How far do you live from here ? A. 20 miles. 

Q. When will you see Prof. Houghton again ? A. To-day. 

Q. Then I will see him about it, and hope hereafter you will 

not only be of service to us, but that we will be some benefit to 

you. 

. .» ♦ 



James Browk, Aged Fifty-two Years. 
Prof. Helmuth. — Tell me about your disease from the begin- 
ning. A. It occurred about three years ago. 

Q. This wrist became affected in the winter time ? A. Yes, sir, 
in October. 

10 



146 . SUBACUTE THECITIS. 

Q. Then you had some trouble about your hip ? A. Yes, sir. 

Q. What kind of trouble was it in your hip ? A. A severe 
pain. 

Q. Had you sprained your hip, or had you rheumatism in your 
hand ? A. I never did. 

Q. Have you had any falls on your hip, or have you hurt it ? 
A. No, sir. 

Q. Then, afterwards, did you take medicine to relieve the pain 
in your joint. A. Yes ; and a great deal of medicine. 

Q. You plastered your hip — and everything else ? A. Yes, sir. 

Q. You don't know whether you were salivated? A. No, sir. 

Q. How long did you have the pain of which you speak ? 
A. Three or four weeks. 

Q. Then, after that disappeared, this trouble began ? A. 
Yes, sir. 

Q. Now tell us about this. What is the trouble now ; does it 
pain all the time ? A. There is no pain at all. 

Q. Is there weakness ? A. Yes, sir. 

Q. You have no power to move the hand ? A. No ; I cannot 
work with it. 

Q. Have you ever slept this way, with your hand under your 
head ? A. No, sir. 

Q. It is not a habit of yours ? A. No, sir. 

(There is a disease occasioned by lying with the hand under 
the head, called wrist drop.) 

Q. You have no pain at all ? A. No, sir. 

Q. And that don't hurt you (making pressure) ? A. No, sir. 

Q. You have been among physicians ? A. Yes, sir. 

Q. And have taken a great deal of medicine ? A. Yes, sir. 

Q. Can you shut your hand? (The patient endeavors to 
squeeze Prof. Helmuth's hand.) 

Q. Is that the tightest you can shut it % A. Yes, sir ; and 
that makes me shake all over. 

He has subacute synovitis and thecitis ; not only a subacute 
inflammation of the membranes, but of the external and internal 
lateral ligaments of the joint, extending into the thecse. This 
is merely subacute inflammation, unaccompanied with pain — the 
same character of inflammation that might ultimately result in 
the formation of a cold abscess. 

Q. What have you applied to it ? A. Ice. 



SUBACUTE THECITIS. 147 

Q. Croton oil ? A. Yes, sir. 

Q. Wet bandages ? A. Yes, sir. 

Q. And it don't get any better? A. No, sir. 

Q. Have you ever taken any homoeopathic medicine for it ? 
A. No, sir. 

Q. Have you had a dry bandage over it ? A. Yes, sir. 

He has had the wet bandage applied to his arm, according 
to directions, and a dry bandage over it, which is very good. 
Now I will put him on a high potency of rhus, and give him two 
powders a day, night and morning. (To the patient.) You 
must take this medicine, and do nothing else. I don't want you 
to mix it with any other prescription. If you are under two 
kinds of treatment neither one will do you auy good. 



jlutgial (&\\m of Jtffoiumj Gift, 1825. 



Dr. J. H. Thompson. — This case of encysted tumor, which you saw- 
two weeks ago, has had nothing done for it except the application of 
strips of adhesive plaster. The sides of the cyst have n6\v adhered, 
as I then told you that they probably would. The action which 
nature has set up here for the cure of this case has disintegrated 
the cyst so that it was not necessary to remove it. Nature has 
performed the entire cure, just as it would if the sac had been re- 
moved before it ruptured. 



T&&®$m?® ®i $%® Xttf e^l^r 



Mr. Paekee, Aged Thirty-six Years. 

Prof. Helmuth. — This patient voluntarily comes before you. He 
is a patient whom I attended for Dr. Belcher. As I have just 
lectured on fractures, I bring him before you in order that you 
may hear tiie history of the case and see the method of treatment. 

The patient states that his jaw was fractured a month ago. He 
was at work in an ice house, and while standing at the bottom of 
an inclined plane, down which the ice passed with great velocity, 
a block of it flew off the side, at a tangent, and struck him on 
the face. 

The jaw bone broke just at the angle v He was rendered insen- 
sible for twenty-three hours, and does not recollect anything about 
it, This large block of ice, coming with such velocity down the in- 
clined plane, must have struck him with tremendous force. For a 
long time after I first saw him he could not get up from the bed, 
because of giddiness, and a certain amount of confusion of the 
brain — all showing that he had received a very severe con- 
cussion. Now his health is very much better, and the bone is 
uniting finely. I will show you the method I use for band- 
aging fractures like this. I first take a square piece of tin, cut 






INJURY TO THE CAUDA EQUINA. 149 

the corners off, and then divide it in the middle like this (cutting 
the tin with pliers). 

It is better to trim it oat on the edge that is applied next to the 
neck. Then bend over the top and bottom to make it fit the chin, 
in this shape (bending the tin into a box shape). 

Then I have a piece of buckskin sewed over the metal. The ad- 
vantage of using tin is that you can measure and cut until you can 
make it fit any sized chin. When it is on, you can hold it very 
tightly indeed; and when Barton's bandage is applied over it, }~ou 
have the parts very securely held. That is just as good a splint as 
you can make. I have treated a great many fractures with such 
a splint, and with good results. Two of the patient's teeth were 
knocked out by the blow, one of them came out and I replaced the 
other. When you are called to treat these injuries of the jaw, the 
first thing to be done is to look for loose teeth, and if you find any, 
remove them ; but if there is any tendency for them to be retained 
in their sockets, it is well to replace them and hold them in posi- 
tion. I have saved this man a tooth by replacing it. The patieut 
states that he now suffers chiefly from pain through the ear. 
That is a symptom of disease about the jaw. He now has the 
incipient symptoms of what may be called "spurious anchylosis," 
which is very easily overcome by the necessary movement. 



Charles Joseph Vander, Aged Ten Years. 
(Mrs.Vander states the history of the case.) This boy, when four 
years old, was taken with pain, and would complain of it on every 
attempt to move or play. A physician treated him for rheuma- 
tism and then for white swelling, and then he applied a splint- 
He coutinued to get steadily worse. He was then sent to Dr* 
Taylor, who immediately pronounced it the hip complaint, and 
said that a splint must be applied. He was under his care for six 
months. No abscess or swelling had then appeared. When the 
pain was very great the doctor directed the extension of the 
splint by means of the key. The doctor kept the splint on for 
four years — always promising to cure him. He would 'give an 
opiate- when there was an increase of pain, but in spite of the 



150 INJURY TO TEE CAUDA EQUINA. 

opium he suffered greatly. It required from three to five drops 
of the liquid opium, once, twice, and sometimes five times in a 
night to get him to sleep. The doctor made plenty of promises 
He kept the splint on for three years, then took it off, and pro- 
nounced the boy cured, and directed that he be taken home and 
turned out and fed. 

Prof. Helmuih. — That is the way they use old horses when they 
turn them out to die. 

Mrs. Vander. — He still suffered a great deal of pain at times. 
By this time the pain had extended to both legs. It seemed like 
rheumatic pain. The boy was then taken to Dr. Schaeffer, and 
he also promised to cure him if put under his care, and said that 
he would have cured him before if the patient had been brought 
to him, and that it was a great pitj r that he had not seen him 
before. Dr. Schaeffer tried all the skill that he was possessed of, 
and continued adjusting the splint and giving medicine, and 
al ways promising. 

Prof Helmuih. — I shall be very careful how I promise anything. 

Mrs. Vander. — This continued until February, a year ago. 
Then Dr. Schaeffer told me that he could not fail after awhile to 
bet otally cured, but wanted me to get Dr. John Wood to tell 
him what was the matter ; but as Dr. Wood was in New York, 
and I live in Brooklyn, I preferred to go to a physician in Brooklyn. 
Dr. Schaeffer wanted to hold on to one leg with a splint, while I 
got Dr. Hutchins to attend to the other leg ; but I was not willing 
he should ; and so I had Dr. Hutchins to attend him for six 
months. He relieved him somewhat of the pain. He said the 
child was suffering from contraction of the muscles. Although 
he relieved him somewhat of pain, the lack of muscular power 
was just as bad. Dr. Hutchins then said that he had done all 
that he could, after treating him six months, and said that he 
would never be any better. Then I called in Dr. Lord. He 
used electricity for six months, and the consequence was that the 
muscles of the leg relaxed, and the pain became much easier. 
Before that the legs were held tightly together at the knee. He has 
had more motion since than he had before the application of electri- 
city. Dr. Lord gave him medicine at the same time, and I think 
that he was benefited quite a good deal by the treatment. There 
is still a great weakness in his spine. He can use his limbs, or turn, 
or roll around, but he cannot raise his body up without great pain. 



INJURY TO THE CAUDA EQUINA. 151 

Prof. Helmuth. — This is one of those cases that need to be studied 
from beginning to end. The disease has been obscure from the 
very first day of its appearance ; and when we see it now, in its 
better developed form, we have no right to cast a shadow of 
reproach upon those other physicians whb have seen it in its 
obscure state, because we do not know when we may ourselves 
have to pronounce upon just such a condition. There are certain 
obscure diseases in surgery, whether in the formation of abscesses, 
imperfectly developed hip disease, or irritation of the spine, which 
are very difficult to diagnose until they are fully developed. It 
is not, therefore, our province to throw discredit on any one, 
because in the earlier stages of the disease the diagnosis was not 
made out as we now see that it ought to have been. Let us 
always keep this before us in surgery. Eather than now blame 
any treatment that has been applied, we will take it for granted 
that these gentlemen all did what they thought was best. No 
matter what school a man may belong to, we cannot believe that 
he is dishonest when he takes charge of a case of this kind, or that 
he does not do his best. It is the lack of proper attention which 
constitutes malpractice. We take it tor granted that the majority 
of respectable physicians, when they have a case of this character, 
do their very best. It is unfortunate when they do not succeed ; but 
it is not for us to sit in judgment upon what they do. Doctors, 
as a general rule, are honest, true hearted men, no matter to what 
school they may belong; and if ministers of the gospel would 
pay half as much attention to the members of their flocks as the 
generality of doctors do to their patients, then, in the day of judg- 
ment, the devil will be most egregiously disappointed. 

In examining this patient I shall first look to see if his prepuce 
is elongated. Sometimes the removal of the prepuce has great 
effect in alleviating these symptoms. There are cases on record 
where simulated hip diseases have been relieve! by the excision 
of the fore skin, strange as that may appear. You s :e that the 
prepuce of this patient is very much elongated. An adhesion has 
been formed on the side. 

Q. Did this child, when he was four years old, have any fall ? 

Mrs. Vander. — Yes; he fell out of his wagon. In going over a 
curbstone the wagon tilted and he fell out. I do not know where 
he struck. That was between the ages of three and four years. 
He appeared to be well afterwards. I do not know that he sus- 



152 FRACTURE OF LOWER THIRD OF THE ULNA. 

tained any injury at the time, but it was during that year that 
he first began to show symptoms of disease. 

Prof. Helmuih. — My own little boy fell out of a wagon in the same 
way when lie was three years old, and he was paralvzed for two 
years afterwards. The splints are off now ; he is twelve years old, 
and he is getting well. 

You can trace this disease straight back to that injury. This 
child has no hip disease ; but he has disease of the Cauda equina, 
or nerves which go down on each side of the spinal marrow, and 
which cause contraction of the adductor muscles of the thigh. All 
of these muscles are very stiff. The use of electricity has done 
him a great deal of good — perhaps more good than anything else. 
I do not promise anything about this patient. I will have a 
consultation with Prof. Burdick about it. I do not think that 
the child has anything the matter with either hip. I think that 
the trouble is in the spine, resulting from the injury that the 
nerves received when he fell. "We move our bodies by the 
muscles that are supplied by the nerves that come from the 
spine ; and if you injure a part of those nerves, a species of 
paralysis of certain muscles usually follows. This boy has a variety 
of paralysis of the rotator muscles. These cases in their incipient 
stages are very difficult to diagnose — much more difficult than in 
an advanced stage like the present. Recollect what I told you 
about the elongation of the prepuce. The first thing, probably, 
that I shall do in this case will be to circumcise the patient. 



Winn* 



Julia Murray, Aged Forty Years. 

History of Case. — (On Sunday last, at about half past 11, as I was 
coming out of the Grand Hotel, I slipped and fell. My feet slipped 
out from under me, and I put my hard behind me and fell directly 
on the wrist. I went back to my hotel, and a gentleman stretched 
out my arm, and then told me to go to a doctor. I went to a 
physician on 31st street and Broadway. The doctor said that the 
bone was broken, and he set it. It gave me a great deal of pain.) 

Prof. Helmuth. — This is a fracture of the lower end of the ulna. 



CASE OF ANEURISM OF THE AORTA. 153 

It does not extend down into the joint, but the bone is cracked 
obliquely. (Removes the bandage and splints.) You notice that 
the Doctor had put on the lower portion of this splint a compress, 
in order to raise the lower fragment. This was very well, but it 
has pressed it up most too high, and it has produced excoriation 
on the under surface. TYe shall apply on this a little tenax, 
put on a patent felt splint, and then the patieut will be more 
comfortable. In putting on the bandage we must be careful not 
to apply it so tightly as to arrest the circulation ; but it must be 
employed so as to prevent the friction of the splint, and because 
she has quite severe excoriations both above and below. We 
will use tenax on each side, and then put on a bandage 
before applying the splint. You must not understand this 
bandage to be the same kind that is used next to the skin 
before we apply a splint. It is merely a substitute for a 
lining to the splint, and that is all : as a rule, a bandage 
next to the skin, unless it be for the purpose of preventing ex- 
coriation, ought not to be used, for it sometimes causes a great 
deal of trouble and swelling. (The Professor asks a student to 
apply the bandage.) A little practice is worth all the talk in the 
world. It is easy to criticise a magnificent picture, and to say that 
this part and that are bad, but it is a very difficult thing to do the 
work yourself. It is very easy to criticise the work of others, 
and very often people criticise things that they could not begin to 
do themselves. The worst critics are generally the biggest asses. 
Now that the bandage is on we will put on Ahll's patent felt 
splint, and secure it with adhesive straps. 



A^^u^i^m p$ $%& A^Hi^i 



I now have a case which it gives me a great deal of pleasure to 
be able to show you. I am apt to be a little careful in my state- 
ments of what can, and what cannot be done by internal medica- 
tion. I am rather disposed to be skeptical, than otherwise, as you 
ail know ; but when I say that I have a case here, that I believe is 
almost cured, of aneurism of the arch of the aorta, I believe that I 
am stating very nearly the fact. At all events I now have a pa- 
tient to show you, who presented all the symptoms of aneurism of 



154 ANEURISM OF THE AORTA. 

the arch of the aorta on the right side ; and who was cer- 
tainly sent home to die. The most peculiar train of symptoms 
were developed in his case, I think, that I have ever known ; 
yet here he is — able to go out; and with a beating of his 
heart that is almost natural. Mr. Porter was a resident of China. 
From what he tells me I infer that there are a great many cases of 
this form of disease in that locality. I do not know why it should 
be so, but so it is. He was first taken with intermittent fever at a 
towm on the Yang-Tse-Kiang River, and had it for nearly a month. 
After that, he suffered a great deal of pain all through his chest. 
Then the doctor ordered a change of climate. (That is always a bad 
sign — when a doctor orders a change of climate you may be sure 
that there is something the matter with the patient.) His trouble 
was called " Rheumatism of the heart." He then went to 
Shanghai and was attended by a French physician ; he stayed there 
a month and improved, but then the trouble began to develop 
again. He had great pulsation from the slightest cause, and all the 
time; he had also a great deal of neuralgia in the side of his head, 
and particularly on the left side. Motion became almost impossible, 
on account of the violence of the pulsation, which any attempt to 
move was sure to produce. He then went four hundred miles fur- 
ther south, but the trouble still continued. There he was treated 
by an English physician, who called the disease aneurism of the 
heart, but did not like to tell the patient any particulars. He was so 
weak that the doctor thought he would die before he could get to 
Japan. Then he went to San Francisco, and visited the Springs ; 
and nearly died while there. The doctor there gave him some 
medicine which relieved him ; for a time he thought that he 
was getting better, and then returned. He arrived there in 
June and had to leave in September. Then he came straight 
through to New York. He was brought to me by Dr. White, of 
Harlem ; and went into the hospital on the 15th of last October. 
When I saw him he had no radial pulse ; he had an enlargement 
on the upper side of the chest, and with a pulsation or bruit, which 
was very well marked, and of tremendous power. He was 
sleepless and restless, and suffered a great deal from neuralgia ; but 
never lost his appetite. His digestion has been good from the first. 
He felt so miserable that he did not care whether he lived or died. 
His heart is now beating rather louder than usual ; which I account 
for by the fact that he has not been about long, and coming to see 



ANEURISM OF THE AORTA. 155 

you and telling his case has given him a little nervous palpita- 
tion. The bruit is now entirely gone. When he is resting in bed 
he is very comfortable. His neuralgia has all disappeared. His 
heart is beating about three times as loud as it generally does, be- 
cause he is a little excited. 

I gave this patient \ drachm of gallic acid three times per day — 
that is about 90 grains per day ; and five drops of sub-sulphate of 
iron three times per day on alternate days. Gallic acid has a spe- 
cific action on the blood, and has a tendency to coagulate it. It is 
one of the surest medicines that can be given to arrest internal 
hemorrhage. I gave him this because I knew of nothing else ; 
and because I had seen two reported cases of aneurism which 
were said to have been cured by its use. Two months before I 
had been consulted by a gentleman from Atlanta, Ga., who bore 
with him letters of several of the most distinguished gentlemen of 
New York, stating that he had aneurism of the aorta ; and who 
had taken iodide of potash in large quantities. I ordered 
him the same treatment I have stated, and have received favor- 
able reports from him. This patient had been under treatment at 
Atlanta, Ga., about a month, when I received this letter concerning 
him : 

Atlanta, Ga., Nov, 30, 74. 
WrLLiAM Tod Helmuth, M. D. 

My Dear Doctor — Dr. Cleveland requests me to write you, 
giving a statement of Mr. F. F. Coulter's case. He was kept on 
gallic acid and per sulph. ferri solution, as you advised, until the 
first of this month, when, upon careful examination, the heart's 
action was found to be perfectly normal. The sufflement spoken 
of in our first has entirely disappeared. Pulse 72 per minute. 
The sound of the pulsation of the heart perfectly clear. There 
yet remained that huskiness of voice and some torpidity of the 
liver. The sclerotica slightly tinged yellow. Discontinued gallic 
acid and per sulph. ferri sol., and put him on digitalis -^ dilu- 
tion, 10 drops three times a day for one week. Improvement set 
in again after second day's use. Sclerotica clear ; skin looking 
better ; tongue cleaned off nicely ; healthy in appearance ; hoarse- 
ness somewhat better ; continued second week digitalis. 

I think from his present condition he will make a perfect re- 
coven^. 

Eespectfully, 

F. F. Fabek, M. D. 



156 ANEURISM OF THE AORTA. 

Having this case in my mind as this patient presented, I deter- 
mined to give this medicine another trial, and so far it has been 
successful. The perturbations of the nervous system which Mr. 
Porter endured, when under treatment with gallic acid were 
very remarkable. For instance, he would lose all control of cer- 
tain muscles or nerves. He would have a piece of beef on his 
fork, and try to put it to his mouth, but suddenly would lose con- 
trol of his arm, and the meat would go over his head. He did not 
appear to have any control over the nerves or the voluntary 
muscles. Before taking the acid his hands were constantly numb. 

I do not offer this treatment to you as homoeopathic. I do not 
know exactly where to put it — whether to call it chemical, me- 
chanical, or what not. I do not offer the remedies as infallible, nor 
do I know that, from the use of such large doses, harm does not 
result to the constitution ; but if in diseases like aneurism of the 
aorta, which is generally and uniformly fatal, and is so acknowl- 
edged, such amelioration as I have shown you can be secured by 
giving these doses; then, until we know of a better plan, it is 
our bounden duty to administer them. If we can employ an- 
other plan, then it will be better to adopt that which is safest. 

This gentleman comes to you of his own accord, at my sugges- 
tion, that I may illustrate the action of these two medicines in 
cases of aneurism of the aorta. I hope and believe, that with 
proper care and attention, he will ultimately recover entirely. 
Whether the pulse will ever return to its regular rate I 
cannot say, but he has none now. At the same time his circula- 
tion is sufficient to keep him in fair health. His spirits have 
been remarkably good. He has got along as well as any patient 
could possibly expect. But it you could have seen him 
when he first came to the hospital, when there was such rapid 
and tremendous pulsation, and he was suffering from neuralgia 
and sleeplessness, you would have thought the case a hopeless 
one. Now, I can scarcely believe him to be the same man, 
From the 3d to the 10th of November he expectorated a great deal 
of blood. This is one of the symptoms of aneurism about the 
larger vessels, particularly the aorta. For a number of days after 
he was put under treatment he spit this blood, accompanied with 
a great deal of phlegm, which nauseated him. That has all passed 
away, and he has been out riding in the park, and seems to take 
an interest in human life, and thinks that the best thing that he 
can now do — is to study medicine. 



pott's disease of the spine. 157 



Anthony Eoul, Aged Four Years. 

We have here another case of spine disease. It seems to me 
that in large cities, spine diseases and affections of the joints — espe- 
cially among the poorer classes — are rapidly on the increase. I 
have had in my office this morning three cases of spine disease, 
and here is another. Whether it is the method in which people 
live, or whether it is the inability of certain classes to obtain 
the necessaries of life, or whether, in the rearing of children, 
people are more careless than they used to be, T am unable to say; 
but certain it is that, in this city, spinal diseases and joint diseases 
are rapidly on the increase. In the country you do not meet with 
them. This is a case of Pott's disease of the spine, in its incip- 
iency. This child had scarlet fever. The mother lost three 
from scarlet fever within a week, and this is the only one left. 
This disense made its appearance after the fever. The first thing 
to be done is to have a proper apparatus put on the child. 



Stephen O'Haka, Aged Fifty-four Years. 
(A felon on the third finger of the left hand, which the doctor 
opened). 

I will apply to this felon a solution of fluoric acid — one part 
to 25 — and one drachm of the solution to be mixed in a 
pint of water, and then apply it. The prescription is thus 
written : 

9 — Fluoric Acid gtt ij. 
Aquae § j. 

M. 
Prof. Burdick. — You must be exceedingly careful to give your 
patients full directions about the use of prescriptions. I once gave 
this prescription to a patient with directions to apply it to the 
finger ; and he did so, without diluting it with water, and the con- 
sequence was he had a lively time. 

Prof. Helmuth. — There is a history connected with prescriptions, 
which of course you know ; and you know moreover that the first 



158 CONGENITAL HERNIA. 

mark of the prescription — " I£" — is considered scientific, being 
a sign of the ancient astrologers or soothsayers. To show 
you how scientific some things may look, which are not scientific 
at all, 1 will write you a prescription — which you can take every 
two hours. 

9 Spiritus Yini. Gall. fl. § ij. 

Tine. Gentian comp. fl. 3j. 
Sacch. alb. pulv. coch. min. j. 
Aquae frigidae fl. g iij. 

Misce bene, et adde corticis limoni sectionem 
parvulam. 
S Ter. die hauriendum. 



Peter Wedin, Aged Eight Years. 

History of Case. — (Hernia commenced when he was only a month 
old. A truss was worn for about twelve months, but it gave so 
much pain that it was then ^discontinued. The intestine remained 
within the abdomen for a while after the truss was taken off. Every 
time he would cry the protrusion would return.) 

Prof. Helmuth.- — This child has congenital enlargement of the 
inguinal canal. I think that he can be cured without very much 
trouble ; but he will have to wear a truss for some time. It must 
not be one with too hard a pad, nor one that will cause him any irri- 
tation. The abdominal rings in children of this age will generally 
close up. If this child could be kept on his back and take some 
such medicine as nux vomica it would hasten the cure. I recom- 
mend the elastic truss, made by Eainbow, which is supported 
from the shoulder. Give him nux vomica three times per day. 



gmyml €>Mt of Jetottwg Uth, 1825. 



(Continued from page 157.) 

Stephen O'Hara, Aged Fifty-four Tears, 
on whose finger a felon was opened one week ago, returns. 

Prof. Helmuth. — In this case we applied fluoric aoid in solu- 
tion (see page 157), and it has done a great deal of good. He has 
not had any trouble with the bone, but there was a considerable 
discharge. I only bring him now before you in order that you 
may see the condition of the hand. You will find in the treat- 
ment of felons that you can always afford a great deal of relief, 
when they begin to suppurate, by removing all of the dead skin, 
which, becoming thickened, from its unyielding character, gives 
a great deal of pain. By taking the scissors and removing this 
you will relieve the patient from much suffering. Sometimes, in 
he earlier stages, you can make these felons abort, by dipping the 
finger in ley, and sometimes by placing around the finger the thin 
white skin which is between the shell and the white of an egg. 
The application of nitric acid is said, also, to sometimes make a 
felon abort ; but when it has progressed so far that the inflamma- 
tion cannot be arrested, then it is better to accelerate the suppu- 
rating process. But in the earlier stages we can, no doubt, prevent 
the formation of pus. It is not necessary to wait until suppuration 
is complete before opening the felon. In this case the process 
was only beginning ; there was but a slight indication of the for- 
mation of pus ; but I endeavored to get the knife down to the side 
of the bone, and the operation has been a success. 



Fraetttr* <of stow*** YfeittA <of i&e 



Julia Murray, Aged Forty Years, 

(Continued from page 152.) 

who was before the class at the last clinic with fracture of the 
ulna, returns to have the arm redressed. 

Prof Helmuth. — The bone is healing as well as it can. I can 



160 FRACTURE OF LOWER THIRD OF THE ULNA. 

feel that there is a deposit of the provisional callous, but I see that 
there is a tendency of the hand to turn inward — to turn to the 
radial side — and therefore we will put on a pistol shaped splint, 
in order to keep it in the right position. In the dressing of frac- 
tures it is astonishing how a little pressure in the right direction 
will prevent what would otherwise result in deformity. If, when 
you remove a splint to examine a fracture, you see that the bone 
is not straight, or that the hand is not in exactly the right position, 
then is the time, by the application of a pad in the right place, 
and by a suitably shaped splint, to prevent further deformity. 

Prof. Helmulh. — Whenever a fracture takes place near the 
joint the inflammation extends into the sheathes of the tendons 
and renders them very stiff, and for that reason passive motion 
is always required. 

(Dr. Thompson applies the bandage.) 

Fractures of the arm unite sooner than those of the leg ; the 
arm unites with tolerable firmness in six weeks ; the thigh and 
leg in eight weeks. 

The union of broken bones is much slower than that of the soft 
parts. The ends of the bone being kept steadily together they 
soon become surrounded by a deposit of plasma, which is grad- 
ually converted into an osseous substance, making thus a bony 
hoop to act as a splint to support the fragments exactly in their 
place. This is called provisional callous, because it only has a 
temporary use. 

Mode of Repair. — The method which nature observes in repair- 
ing lesions of the osseous structure is most beautiful, and, when 
carefully noted, may be divided into several stages. 

The first stage is a period of rest or incubation. The inflam- 
matory lymph is thrown out around the site of injury, which may 
occupy two or three days. The tissues during this stage are soft 
and somewhat succulent, and infiltrated with a fluid resembling 
serum. This is the period of true rest, so far as the ends of the 
bones are concerned, which remain in a quiet condition, while 
nature removes the debris, clears away extravasated blood, takes 
away the swelling, and prepares for the second period. 

The second stage is the period of uniting the fragments together. 
This is accomplished by the deposition of a fibro-gelatinous sub- 
stance, of a slightly reddish tinge, which surrounds the extrem- 
ities, as it were, with a pad, holding them together. This sub- 



FRACTURE OF LOWER THIRD OF THE ULNA. 161 

stance may also be poured out, though in a lesser degree, in the 
medullary canal, thus giving support both externally and inter- 
nally to the fractured ends of the bone. This substance gradu- 
ally, and in different ways, is transformed into the so called pro- 
visional or intermediate callus. 

This substance is not bone ; but in the deposit around the 
fracture, points of bone begin to be deposited, the fibrine poured 
out, becoming first cartilage, and then receiving into itself phos- 
phate of lime, it becomes bone. A similar work is going on 
within, in the part called the medullary canal. 

Then begins the third stage, which goes to the end of the sixth or 
eighth week. During this period the external and the internal 
deposits become completely ossified and firm, though the ends of 
the bone are not yet grown together. 

The fourth stage extends to the end of the fifth and sixth month. 
During this time the external or provisional callus becomes cov- 
ered with a periosteum, and the ends of the bones themselves are 
fastened together by a bony deposit. 

The fifth stage extends from the fifth or sixth, to the twelfth 
month. Daring this time the ends of the bone become grown 
together so strongly that the bony ring or provisional callus is no 
longer wanted, and it becomes absorbed and disappears — in other 
words, having no further use for it, nature takes off her splint. 
The point of fracture is now as strong as any other part. 



The union of compound fractures takes place in a different man- 
ner from that of the simple fracture just described. In this case 
there is suppuration, and the bones remain disunited several weeks, 
and there is no provisional callus formed. But after some time 
the ends of the bones soften and granulate ; and when the produc- 
tion of pus declines, the granulations are giadually changed 
into bone. 

Prof Helmuth. — To a student of the class : 

Q. Can you describe fracture of the lower jaw ? A. It gene- 
rally takes place near the chin. It may occur also near the 
angles of the jaw. It may be simple or compound, and is 
known by the pain, the swelling, the inability to move the jaw, the 

11 



162 INFLAMED ULCER. 

indentation felt by the finger, the irregularity of the teeth, and the 
grating sensation felt while moving the jaw with the hand placed 
on the back fragment. 

Q. In a fracture of the lower jaw, what is the best bandage to 
be applied ? A. The figure 8 bandage. 

Q. Who introduced the figure bandage ? A. John Rhea Barton 
one of the most promising surgeons that the United States ever 
knew ; and who made himself immortal by the operation for an- 
chylosis of the knee joint, which bears his name. 

Q. When suppuration is progressing, does the patient sweat? A. 
When suppuration is going on in the body, particularly if there is 
any amount of pus forming, there is profuse sweating. This is one 
of the symptoms of the disease. Not only is this sweat profuse, 
but the character of the coldness and shivering is peculiar, and 
appears at regular intervals. Many a case of suppuration in 
malarious localities has been mistaken for intermittent fever. A 
chill comes on in the afternoon, followed by fever and profuse 
sweat ; and these are the symptoms which may lead you astray 
when suppuration is about to commence. It is by means of these 
s\'mptoms that we diagnose the formation of cold abscesses in ob 
scure places. 



Sophia Bartlett, Aged Forty-one Years. 

History of the Case.-^-" I have had this sore on my leg for about 
a month. At first there came an inflammation extending about 
three or four inches. Then three or four purple marks came 
around it, and it spread rapidly. It br >ke the next day. When 
it first made its appearance, I put sweet oil on it, because I 
thought it was only a little pimple. Then I put on spermaceti 
ointment, to cure it. Then I was told to use Daily's salve. The 
inflammation still kept spreading." 

Prof. Htlmuth. — Here is a case of irritable ulcer, or, what 
should more properly be called in the wider classification, 
" an inflamed sore." You will recollect that this variety is 
different from the irritable, because the inflammatory action 
seems to extend to a greater degree around the former. When 
we have an inflamed sore we not only have the ulceration which 



INFLAMED ULCER. 163 

is extending at the localized point, but we generally have a dif- 
fuse inflammatory action throughout the connective tissue 
Ultimately, this high degree of inflammatory action will disappear 
and the patient will seem to be better constitutionally ; but we 
will have a change taking place in the surface of the ulcer itself; 
and then will present the old fashioned variety of ulcer, with no 
disposition to heal, and with scarcely any granulation visible. 
These are the sores that we frequently see in persons of her 
position in life, who are unable to lay aside work. If she 
could go home and secure the right kind of treatment — which we 
will prescribe — keeping her leg in an elevated position for three 
or four weeks — that ulcer could be cared without the slightest 
difficulty. But if we have to strap it, and support the parts 
with a bandage, so that she can perform the ordinary avocations of 
life, it will be a very different thing to munage, and the cure 
will be tedious. The patient says that her foot hurts her more 
when it is elevated than when it is down. Why is this? 
Because the parts are in a congested condition ; but if she will 
persist in keeping the foot elevated, and let sufficient blood out of 
the distended capillaries, then the reverse will be true ; and she 
will have less pain when the foot is elevated than when it is de- 
pendent; for when it hangs the blood will rush into it and it will 
begin to throb, and beat, and burn. In such a condition as this, 
the first thing to be done is to allay the local irritation. The 
diffuse inflammatory action is extending along the connective 
tissue and renders any pressure upon the foot almost unbearable. 
The best thing to reduce this inflammation is a simple cold water 
application. 

She must keep the leg elevated ; then take a piece of canton 
flannel, or old muslin, and fold it four times upon itself; dip this 
compress in cold water, wring it sufficiently to prevent its drip- 
ping, and envelop the leg therewith ; over that, wrap a piece of dry 
canton flannel, and over that, a piece of oiled silk, and tie it on 
with three or faur tapes. I venture to say, that she will not have 
the wet bandage on that sore but a few minutes before the rag will 
be so dry that it will have to be rewetted. She will have to keep 
rewetting it as often as it becomes dry. As the inflammatory 
action disappears, it will take longer for the bandage to dry. For 
the first day or two it will have to be wet two or three tiaies in 
an hour. She must keep her leg on a chair, and the water by 



164 TRAUMATIC GANGRENE. 

her side, and as often as the bandage becomes dry, remove it, wet, 
and apply it over and over again. Internally, she had better have 
aconite. After the inflammation has subsided we will then come 
to the treatment of the ulcer. What shall we do with that? Put 
mud or dry earth on it. The wet earth treatment is almost as 
good as the dry. If you apply earth after the inflammatory 
action has subsided you will find that in less than four days you 
will have a granulating surface where there is none now. During 
the first three days the foetor and the discharge will increase, then 
a slough will separate from the centre of the sore, and you will 
have a granulating surface appearing. You can continue ap- 
plying the earth, and if you desire to hasten the cure you can 
strap it every day, and give internally silicea, calcarea, mercurius, 
or any of the medicines which the constitution seems to indicate. 
But in the first stages you must give medicines to subdue the con- 
stitutional disturbance and keep the blood out of the capillaries ; 
then give something to stimulate the ulcer, and, finally, promote 
the process of granulation and cicatrization. 



I expected that I would have an amputation to perform this 
morning, but the case would not keep. It was a bad case of trau- 
matic gangrene — worse than I had any idea of — and as soon as I 
saw it, though it was at night, I was obliged to remove the arm. As 
I told you, when speaking of traumatic gangrene, you are never to 
wait for the line of demarcation. The accident in this case occurred 
on Monday night. On Tuesday I received a telegram, asking if I 
could come over and see it. I telegraphed back to bring the patient 
to the hospital. He was caught between two cars, he does not 
know exactly how, and the arm was terribly mangled I did not 
see the case until Thursdaj' at half past four in the afternoon, 
and then the gangrene was rapidly extending. In three hours it 
had increased two inches; and, at half past seven in the evening 
I could barely find flap enough to make Larrey's amputation at 
the shoulder joint ; however, I succeeded in so doing. When I 
took hold of the tissues I could feel them crepitate in my fin- 
gers. The veins across the shoulders were very much enlarged, 



HIP JOINT DISEASE. 165 

showing that the gran gene was invading those parts. I do not 
now know what will be the result of the case. When I heard of 
it I thought it was one which would keep for a few days, and 
that I could bring it before the class; but it was ordained other- 
wise. The man would not have lived through the night. 



AUGUST SiSSMAN, Aged Twelve Years. 

(Continued from pages 60, 105, 116 and 142 ) 

Here is our friend August Sissman. I told him to come at the 
last clinic, and here he is. He is very much improved in every 
way. (Holding up the splint which the boy had taken off.) 

The counter extension in these splints is made by means of the 
perineal band, which passes up into the perinaeum and fastens 
to the crutch at the top. The extension in this case is made from 
the shoe. In Dr. Taylor's splint the extension is kept up contin- 
ually, and there is a bar that goes across under the foot, In Dr. 
Sayres' splint there is no shoe, but the extension is maintained 
by bands of adhesive plaster, which have a tendency to draw the 
leg down. Recollect that the Bauers' splint has the shoe ; Tay- 
lor's, the bar of iron under the shoe ; Sayres', held in situ by 
adhesive plasters. 

You see that these sores have nearly healed, and, if it were not 
for the friction of this splint, the larger one would be closed en- 
tirely. The openings behind are not yet quite cured. You will 
recollect what an aggravated case this was. You see that his leg 
has come down about two inches and a half. This was a case in 
the third stage of hip disease ; the improvement so far has been 
quite remarkable. There is some diseased bone there yet, which 
may ultimately necessitate an excision of the head of the femur. Dur- 
ing the time he has been under treatment the leg has lengthened ; his 
appetite is good, he sleeps well at night, he has less pallor, and no 
hectic flush. Taking all of these symptoms into consideration, we 
can say that there has been a general improvement i.i his case, 
which is indicated by these favorable constitutional symp- 
toms. We can say, that the hopes of recovery are good, when we 
see that the constitutional tendency of the patient is to improve. 



166 CONCLUDING REMARKS. 

If he was run down like the man Hart, whom you saw, there 
would be but little lope. Hart, you will remember, had two or 
three openings into the scrotum. In such a case an operation 
would have been entirely out of the question. He died in a 
most miserable condition, worn out by the constitutional irrita- 
tion and the profuseness of the discharge. At the time he was 
here he had twenty-eight openings. The discharge was so great 
that when he would raise up he would leave about two quarts of 
pus in the paper which was used as a dressing. 

This patient is a great deal better in every way. He has had 
nothing internally but calcarea and silicea. 

Prof. Burdi'ck, of the obstetrical department, proposes next 
week to honor us with the presentation of his prizes, which will 
assist to leave pleasant memories not only of these clinics, but of 
all who have taken part in them. I hope that when you come to 
the practical part of your profession — particularly in the obstetri- 
cal department — you will be able to know a head presentation 
from a wind bag ! 

Our clinics this session have been remarkably well attended and 
supplied with patients. They have been attended not only by the 
gentlemen of the class, but by outside physicians, and by mem- 
bers of the faculty, who have been regularly present. I regard 
this, not only as complimentary to you, but also as a compliment 
to myself. We were carried a little cut of our usual line in 
clinics, by the case of subclavian aneurism, and, because of our 
attention to that subject, we were not able to lecture much on 
amputations. I believe that when we have finished with the latter 
we will have gotten through a pretty complete surgical course. 

When we take into consideration the number of patients we 
have had at these clinics, I think we may congratulate our- 
selves, that the facilities in the surgical department of the Homce- 
pathic College have been equal to those of any institution extant. I 
do not say this as a boast ; I only mean to say that I am supplied 
with facilities for teaching, and it affords you opportunities for 
seeing, the practical results of medicines administered according to 
the homoeopathic law. 

I long ago made it a rule never to perform operations before 
the class which all could not see, because those operations 
are not only uninteresting to lookers on, but they become very 
tedious. Therefore, while I have lectured upon, and shown you 



CONCLUDING REMARKS. 167 

cases of cleft palate, fistulas, and diseases of the nose, I have per- 
formed the operations at the hospital and brought the patients 
here to you afterwards that you might see the results. I trust, 
therefore, gentlemen, that though you have all had a great deal to 
do this winter, that you have had some pleasant times at these 
clinics. Next Monday week is the birthday of Washington, and is 
properly regarded as a national holiday ; I shall, however, con- 
tinue my lectures on amputations, and, although I do not make 
the attendance at all compulsory, I would like to see as man}' of 
you as possible here, because I have been unavoidably detained 
from lecturing on that subject, having so much to teach on aneur- 
ism. After I had lectured to you on the case of cleft palate I 
took the patient to the hospital and operated. Probably only 
two or three could have seen it had I closed the cleft here. 
I always endeavor to bring before the class all the operations 
which can be seen ; but those which are tedious I prefer to 
do elsewhere, and bring the report of the case, with the patient, 
or perhaps the specimen, before the class, so that you may know 
the result. 

Of all the lectures that I deliver I regard the clinics as the 
most agreeable. I like them, because I endeavor to make them 
a little free and easy for you, and because I can vary a little in the 
subject. If there is anything that I do dislike, it is to occupy an 
entire hour talking on one dry subject, without variation. Many a 
time I have stopped and told a story, when I have seen a man 
nodding. Just as soon as the little narrative begins, he wakes up 
and is as bright as a dollar. 

As this is the last clinic before examination I have to thank 
you very kindly for your attendance, and for the decorous manner 
in which you have always conducted yourselves in my presence, 
not only in the clinics, but everywhere else. So far as I know, not 
a single unpleasant circumstance has occurred between us, to 
mar the harmony of our friendship, which I hope will long continue 
to exist. If, at any time hereafter, when you have received your 
"sheepskins," and enter upon professional life, I can be of the 
slightest service to you in surgery, you can always write to me, and 
I will do all that in me lies for you. But do not be egotistical. Do 
not, if called to a case you do not understand, endeavor to treat it 
entirely yourself. If you do not send for me, call for some one 
who makes such cases a specialty. Rscollect it is no disgrace to 



168 CONCLUDING REMARKS. 

say " I do not know." It is a great deal better to say " I do not 
know, but I will call a consultation," than it is to be sued for 
$10,000 damages. Nine tenths of the suits for malpractice could 
be avoided, if consultations were called at the proper time. Young 
men have very erroneous ideas about consultations. They think 
that summoning a brother physician in counsel, proves derogatory 
to their wisdom as doctors. So they hold on to a case in the 
hope that it will all come right in the end. Although dame Nature 
does a great deal for surgery, and helps the doctor out of a great 
many scrapes, it is better not to urge her too far. Therefore, when 
you have an obscure case, do not be afraid to ask advice ; and 
if you cannot get it where you are, you will always readily receive 
it from the New York Homoeopathic Medical College. Whether 
I am here or not, you may be sure the desired assistance and infor- 
mation will come. But if you disregard your Alma Mater, some- 
time she may disown you. 

Gentlemen, when you return to your homes, and look back 
upon this course of lectures, I trust that you may consider these 
clinics as among the pleasantest hours of your student days. 

To Prof. S. P. Btjkdick, Dr. J. H. Thompson, and to all who 
have assisted us in these surgical clinics. 

Gentlemen — For the students and myself I tender you our best 
regards, wishes, and many thanks for the obligations we are under 
for the valuable services you have rendered to the class ; and for 
the many interesting cases you have presented for our instruction. 
We regret that the end of the clinical term has come, but trust we 
shall see you at our next session of 1875-76, which promises in 
every respect, to prove equal, if not superior in clinical facilities, 
to the one which is now passed. 



New York, February 25th, 1875. 
To Prof. Helmuth. 

My Dear Doctor — I offer to you this Eeport of jour Surgical 
Clinics as a token of my regard and respect for you, and for your 
ability as a Clinical Teacher. I have no expectation of pecuniary 
or other reward from you or the New York Homoeopathic Medi- 
cal College for the labor I have undertaken, save the approval of 
yourself and the Faculty. 

Yours, very truly, 

PHILETUS J. STEPHENS. 



REPORT OF THE SURGICAL CLINICS HELD 

AT THE NEW YORK HOMCEOPATHIC 

COLLEGE BY WM. TOD HEL- 

MUTH, M. D, FOR THE 

SESSION OF 1873 
and 1874. 

Acute ffi®®&®mim* 



Josephine Walsh, Aged Nine Years, 
was taken three months ago with swelling of cheek, with 
general febrile condition. Four teeth were extracted by a dentist, 
which aggravated the symptoms. She then had a very offensive 
breath, with profuse discharge of saliva and pus. Five weeks ago 
an abscess formed and discharged itself under the chin, after 
which the breath was not so offensive. Probe introduced, rough- 
ened and loose bone encountered. 

Pronounced acute necrosis of inferior maxillary. Merc, proto- 
iodide 30, grs. ij., night and morning for one week, and parts 
syringed twice a day with Lister's sol. carbolic acid. 

Nov. 1, Better. Treatment continued. 



Empyema* 

James B. Corkey, Aged Twenty -one Years. 

Pleuritic abscesses on left side below nipple, the lower one 
admitting probe one half inch ; discharge freely; have existed 
fifteen months ; oedema of both legs ; mother died of phthisis. 

Pronounced empyema caused by pleurisy. Sulphur 30 trit., 
powder every night, with injections of carbolic acid. 

The differences between empyema, emphysema and hydro- 
thorax were pointed out, and the causes of the dropsy 
explained. Allusion was also made to the immense amount of 
purulent formation which could accumulate and be discharged. 
The method of puncturing the thoracic walls with the aspi- 
rator, an instrument which has of late attracted great attention 
from the profession, was explained. 



172 CLINICAL RECORDS. 

Amjmt&tion ot Breast 

Mrs. Cunningham, Aged Forty-eight Years. 

Encephaloid tumor of left mamma, size of walnut, hard, purple 
and unbroken. Etherized, and tumor dissected out down to ribs 
and sternum, leaving an opening several inches in diameter. 

She had been operated on by Prof. II. sixteen months ago for 
a similar tumor, and was then told that it would return. Pre- 
vious to first operation the tumor had almost disappeared 
under conium mac, prescribed by Dr. Dunham, when an 
injury reproduced it. Wound sprayed with carbolic acid, 
packed with carbolized cotton, and adhesive straps applied. 

Wound showed healthy granulations, and good recovery 
expected. It was strapped firmly to bring edges of wound 
together, and Fowler's solution, gtt. ij., twice a day, ordered. 
The only unfavorable symptoms following the operation were 
intermittent pulse, found to be idiopathic, and retention of urine, 
which was relieved by aeon, and canthar. Strangury, retention 
of urine and intermittent pulse often follow operations, and the 
last may be a bad indication, and dangerous in inverse proportion 
to the strength of patient's constitution. In a few days more the 
patient left the hospital, the wound having healed very kindly. 



Tilling Jtqtti&e+Vara** 

Wm. Dohn, Aged Four Years, 
Talipes equino-varus, operated upon one year ago, but opera- 
tion rendered fruitless by the patient not wearing the proper 
shoe. Tendo Achillis and tibialis anticus divided subcuta- 
neously, and shoe ordered to be worn at once. 



Bridget McNally, Aged Fifty-four Years. 

(See Page 30.) 

Passed climacteric ten years ago. Two years since a small 
hard lump appeared in right mamma; it was painful ; the nipple 
was retracted. The integument then ulcerated, and the peculiar 



REPORT OF SURGICAL CASES. 173 

granular appearance, with occasional hemorrhages, which belong 
to epithelioma, was noticed. The two different varieties of epi- 
thelioma, superficial and deep seated, were explained, and the 
arguments for and against operative measures in cancer pointed 
out. The value of ars., hydrast, conium, sepia, and phytolacca 
were noted, and the patient promised to return at the next clinic. 



Margaret Cauldwell, Aged Forty-eight Years. 

Sebaceous tumor of the scalp, situated in the occiput; appeared 
two years ago. It gave but little inconvenience, but was growing 
rapidly ; it had actained the size of a large walnut. Dissected out 
entire. The various forms of cystic tumors were mentioned. 



Mrs. K., Aged Foity-five Years. 

This case was a very aggravated one, had existed for a number 
of years, was accompanied by anal spasm, and rendered the patient 
very miserable. Hemorrhoids removed by the platina wire 
brought to a white heat by the galvano-caustic battery. There 
was no hemorrhage. The fissures were divided throughout their 
extent. The cure of fissures and cracks about the anus may be 
sometimes accomplished by the forcible dilatation of the sphincter. 



Jos. Brotherfield, Aged Five Years, 
Brought here supposed to be tongue tied, but it was discovered 
that he had nursed well, could talk fairly, and project tongue. 
Slight impediment in speech, due to lack of education of certain 
muscles. No operation required. 



174 CLINICAL RECORDS. 

Sjpurious Anchylosis of XZn.ee 



Lena Elcesse, Aged Six Years, 

Two years ago fell and injured her knee, which became very 
much swollen. Iodine was applied, then she was put in bed, 
and extension by means of a two pound weight kept up. Spurious 
anchylosis took place nine months ago, and Professor Helmuth 
divided tendons of external hamstring, and ordered motion. She 
can now walk fairly, but there is still much swelling of the joint, 
with atrophy of muscle of the leg. Rhus tox. internally. Anchy- 
losis splint ordered. 



Rachel McPherson, Aged Fourteen Years. 

Spurious anchylosis of right shoulder. 

Humerus closely adhered to scapula, which latter had great 
latitude of motion ; crepitus fell on motion ; pain worse in 
winter. Had taken rhus tox 3, one year ago without effect. Anchy- 
losis from chronic rheumatic arthritis. Operation recommended. 



Mks. S., Aged Forty -two Years. 

Tumor beneath middle third of clavicle ; came two months ago. 
Pains like sticking with a needle; no pain from pressure; firmly 
adhered to subjacent structures. Pronounced enchondroma, and 
she is to return in a fortnight for removal. The peculiarities of 
cartilaginous growths were mentioned, their connection with 
bones, and those most obnoxious to their formation were 
alluded to. 



REPORT OF SURGICAL CASES. 175 



Joanna Schanahan, Aged Twenty-four Years. 

Sebaceous tumor of the scalp, which was already suppurating, 
was left to take care of itself. Very often, either from injury or 
from efforts of nature to remove abnormal formation, suppuration 
occurs in cysts, and cures may be spontaneous. In this case such 
a process is going on, and a cure may probably result. Adhesion, 
either taking place within the walls of the sac or the cyst wall, 
being removed by ulceration. 



John Forsythe, Aged Nineteen Years. 

Tumor of right little finger, palmar surface hard, movable ; is 
accustomed to lift heavy packages ; noticed first appearance about 
a year ago, after a sprain ; feeling of crepitation along flexor 
tendons of the wrist when exercised. Pronounced enlarged 
bursa of flexor tendon, with diffuse ganglion at wrist. The 
contents of a bursa vary ; sometimes it is a straw colored 
fluid, sometimes of the consistence and appearance of honey ; 
sometimes it resembles the vitreous of the eye; sometimes 
there are cartilaginous formations, which are discharged, which 
resemble the seeds of a melon ; this variety of growth is called 
a melon seed bursa. A ganglion is an adventitious bursa. 
Bursse are subject to inflammation, which may terminate in 
suppuration, and even gangrene. Sometimes bursas rupture 
spontaneously. The methods of treatment are: sudden forcible 
pressure; puncture with scarification of sac internally to cause 
adhesions; painting with iodine externally and internally; 
longitudinal incision along palm of hand to relieve traction ; 
insertion of seton through the sac. In this case a seton was 
passed through the sac, and cantharides applied to palm to 
blister. 

Some improvement ; crepitation partially disappeared. Can- 
tharides collodion continued. 



176 CLINICAL RECORDS. 

No improvement since last week. Palm so hard cannot be 
blistered by cantbarides. Apply croton oil ; take internally 
iodide of potash, and use continued pressure. This case returned 
in a week, being very much relieved. The treatment continued. 



John S., Aged Sixty -six Years, 
About two months] since injured his head by striking it foroibly 
against a door. Periosteal inflammation was set up ; pain severe, 
worse at night. Now a node presents itself, which is painful on 
pressure, and fluctuates. On lancing, there exudes blood, and a 
very fetid pus, produced by caries. Pronounced periostitis and 
caries. Ordered wound to be packed with lint saturated with — 
I£ Carbolic acid, 3 j. 

Sweet Oil, 3 v. 

Water, 3iij. 



Grace Brinkendal, Aged Eight Months. 
Capillary naevus on forehead ; operated on five months ago, but 
has returned. Operation performed by placing suture pins through 
the tissues under the nsevus in the form of an X, and drawing 
tense a ligature under these pins. If nitric acid is applied as soon 
as the red spots appear it will destroy the nsevus, if small. Con- 
tinued pressure is another means used to kill nsevi. The methods 
by galvanic puncture, vaccination, etc., were explained. 



Pat Whalen, Aged Fifty-six Years, 
Thrown from a wagon two months since, striking his shoulder, 
in which joint there is dull, aching pain, worse at night. He was 
made to go through the motions which diagnose dislocation, and 
the various positions explained to the class. There were no signs 



REPORT OF SURGICAL CASES. 177 

of luxation, and the affection was pronounced synovitis. Rhus 
tox. topically and internally. Synovitis may, unless treated, pro- 
ceed to spurious anchylosis ; but the timely administration of 
nudicine and passive motion will, in the majority of cases, prevent 
such a result. The diagnosis between spurious anchylosis and true 
synostosis was entered upon and explained at length. 



Mr. Turner, Aged Sixty-four Years. 

About five years ago inflammation began at inner canthus of 
left eye. Gradually the erosion has extended, now involving the 
lower lid. Resembles epithelioma. Diagnosis obscure. Pus must 
be examined for epithelial cells with microscope. A portion of the 
discharge was obtained for this purpose, and, in the meanwhile, 
prescribed hydrastis 6m. 



Hugh Kelley, Aged Thirty -six Years. 

Operated on seven years ago at Brooklyn Hospital. Owing to- 
imprudence the cut has never properly healed. The sinus was 
slit up and the fissures divided at the bottom. The wound was 
packed with prepared lint. The first appearance of fistulae, their 
varieties, and methods of treatment, by knife, ligature, paralyzing 
the sphincter, and internal medication, were detailed to the- class. 



Edmonis Walker, Aged Twenty Years. 

Fungus growth and ingrowing toe nail of left great toe, which, 
had existed for several years. On cutting into the fungus it was 
found to be an osseous growth from the phalanx, probably pro- 
duced by irritation by the ingrowing nail. The whole outgrowth 

12 



178 CLINICAL RECORDS. 

was excised, with the ingrown portion of the nail. Usually a very 
good treatment for ingrown tee nail is to shave its middle with 
glass, cut a notch at the apex of the nail, and raise the edges by 
placing underneath them small bits of lead. 



Antoine Lavelle, Aged Thirty-three Years. 

Diffuse adventitious bursa at wrist. About three months 
since wrist sprained and bruised by a fall ; has gradually increased 
in size ; crepitation present. Apply pressure and blister. Intro- 
ducing seton would in this case probably cause contraction of 
tendons. 

Much better under cantharides application. 



8-&a&d*&ftid*j» R&*$: 



Miranda Koy, Aged Twenty-nine Fears. 
Housemaid's knee is an enlargement of the bursa under the ten- 
don of the extensor muscles of the thigh. It had not proceeded to 
ulceration. Ordered compress and cantharides, with leg as much 
as possible in horizontal position. May become necessary here- 
after to inject iodine to excite adhesive inflammation. " House- 
maid's knee," "weaver's bottom," "miner's elbow," "bunion," and 
the enlargement found in severe cases of talipes equino-varus, 
were described. 



CaviiSag*** 



Albert Swan, Aged Sixteen Years. 

Disease of knee joint. Ten years ago fell on the ice. Inflamma- 
tion and suppuration followed, and spiculse of bone came out. 
Has improved very much for the last six months under silicea, 
which is continued. In the first stage of this disease, when caused 



REPORT OF SURGICAL CASES. 179 

as above, a blood-blister is formed, and, although there is little 
pain, then is the time to commence treatment. If no care is 
exercised, inflammation proceeds to suppuration. All pressure 
must be taken from the joint, and the patient not allowed to walk. 



Tttme? ®m Sfo*3t* 



August GtRIESS, Aged Thirty-four Years. 

Tamor of the size of an orange on left side of neck, under 
superficial fascia ; lobulated ; supposed to be cystic : fluctuation 
detected. Began to grow about eight months since. Operation 
postponed at request of patient. 



A. B., Aged Twenty-six Years. 

In hypospadias the outlet of the urethra is on the under sur- 
face of the penis, in epispadias the opening is on the upper sur- 
face ; the disease is congenital. In this case the opening is in middle 
third of the corpus spongiosum, no normal meatus being present. 
There is also fissure of the glans. Penis is bent as in chordee. 
Urethroplasty may be performed for the cure of this affection, but 
in this case no operation was desired by the patient. 



Katie Ward, Aged Twelve Years. 

Swelling of left mammary gland ; not painful. Has been 
painted with iodine, and improved under it. Prescribed phos. 30 
once a day for a week. The use of this medicine in hypertrophy 
of the mammas, as well as in mammary abscess, was highly 
extolled. 



180 CLINICAL RECORDS. 



Denis McDonald, Aged Forty six Years. 

Fistulous opening in right thigh, lower third, from caries of 
femur. "When a bo} 7 , injured the thigh, and spiculae of bone came 
out. Two years ago last May a small tumor appeared on outside 
of thigh, which grew, and, in about four months, burst, and from it 
exuded pus, which has continued since. Probing discovers caries, 
but not necrosis. 

Prescribed silic. 20 °- Hopes to cure without use of knife. Carious 
bone under the probe has a granular feel. Above case has been 
at other college clinics without benefit. 



W<ow*4 ^f S^i**}** 



James Leet, Aged Fifteen Months. 

Laceration of tissues of roof of mouth, from falling on a key. 
Some of the tissues hung by a pedicle, necessitating sloughing if 
left to themselves. These tissues were excised with scissors. 



• Aa<*9w}<**£n <of 3t<*w*¥ 



Mary Beatjmet, Aged Sixteen Years. 

(See page 83.) 

Spurious anchylosis of lower jaw, from gangrene of the mouth. 
Cicatrix extensive and firmly adhered to jaw. The adhesions 
were very fibrous, and were divided carefully within the mouth 
with the knife ; then Westmoreland's ^instrument was applied 
and the anchylosis broken up. On the inside, between the cheek 
and jaw, was placed a moderately thick layer of tin foil, to prevent 
the adhesions recurring. Ordered to move the jaw every three 
hours, forcibly, to prevent the return of the anchylosis. 

The diagnosis between false and true anchylosis of the jaw is 
this : If the patient can produce contraction of the masseter musole 



REPORT OF SURGICAL CASES. 181 

the anchylosis is spurious. Anchylosis, as regards position, may 
be of three kinds: 1. The condyle may be fixed in the glenoid 
cavity. 2. The coronoid process may become attached to the zygoma. 
3. The adhesion may take place between the upper and lower 
alveolar processes. The first is by far the most common form. 



in* 



GrEO. Pierce, Sailor, Aged Fifty-one Years. 
Fell, about a year and a half ago, and. fractured his jaw about 
one inch to right of symphysis. Bones were not properly ad- 
justed, and necrosis of part of inferior maxillary has taken place. 
For last six months his general health has improved, and the 
separation of bone promoted by the use of hecla lava. 



tHfluse ^4^0^iU0i*# Sia^Jim* 



Much better, under local application of cantharides and con- 
tinued pressure. Treatment continued. 



Bursa, 



Antoixe Lavelle, Aged Thirty-three Years. 

(Continued from page 178.) 

Much improved, less crepitation, under croton oil to blister, and 
internal administration of iodide of potash. Continue iodide of 
potash. 

Crepitation at wrist has entirely disappeared, but the bursa at 
little finger, not yielding to previous treatment, was dissected out. 



Henry M., Aged Six Years. 
The first step of the operation for the removal of this condition 
is to reestablish the urethral opening anterior to the seat of the 
affection. This must be accomplished by means of a blunt probe ; 



182 CLINICAL RECORDS. 

otherwise extensive laceration may occur. The adhesions must 
be prevented from recurring. The second step can be performed 
after a few days, and consists in the occlusion of the hypospadias 
with sutures, and the introduction of a catheter, to carry off the 
urine, that it does not come in contact with the inflamed parts. 
This operation is not always successful. 



Nancy F., Aged Forty-eight Years. 

Necrosis of the bone of third finger of right hand, resulting 
from a fall. Nine weeks ago amputation was performed, the 
case being treated at the College Dispensary. The disease has 
recurred. Amputation is now necessary, a second time. In 
amputations, leave sufficient flap to prevent retraction. Dr. 
Thompson then reamputated at the meta-carpo-phalangeal bone. 

(Professor Helmuth described Esmarch's new method of pre- 
venting hemorrhage in amputations.) 

Necrosis still showing in the stump, although the operation was 
well performed. Mal-nutrition of bone the cause. IjL silicea, 30, 
once a day. 



Jane S., Aged Twenty -seven Years. 

Six years ago fell upon her knee. Immediately afterwards there 
were no alarming symptoms, but in a short time the knee began 
to enlarge, and the disease commonly denominated white swelling 
resulted. This state continued until one year ago, when an ulcer 
appeared on the anterior surface of the leg, below the patella. This 
ulcer has now reached the size of a man's hand, and is spreading 
rapidly. Has profuse fetid discharge. Patient has bone pains at 
night and headache ; has had sor j throat, an 1 had, some time since, 
an ulcer at ankle joint of opposite leg. The appearance of the 
ulcer, together with the above symptoms, are sufficient indications 
of syphilitic taint. 



REPORT OF SURGICAL CASES. 183 

Prescribed iodide of potash, grs. ij., four times a day internally, 
and topical application of carbolic acid spray (Lister's sol.). In 
this case the constitutional taint was inherited from the father. 
Among the antidotes for the syphilitic poison iodide of potash is 
certainly one of the very best. 



J. E. H., Aged Five Years, 

has double oblique inguinal hernia, which has become scrotal. 
Cough impulse perceptible, tumor opaque, congenital. Hernia 
maybe confounded with hydrocele, which may also be congenital. 
The following are a few of the points of differential diagnosis : 

Cong. Hernia. 
1. Appears from the top of 
scrotum. 



2. Is generally opaque. 

3. Has cough impulse. 

4. Testicle felt at bottom of scro- 

tum, distinct from tumor. 



Hydrocele. 

1. Appears first at bottom of 
scrotum. 

2. Is more or less translucent. 

3. Has none. 

4. Testicle scarcely felt, if at all. 



The testicle, in its descent through the ingunial canal, may 
lodge at the ring and simulate hernia. To determine whether 
this be the case, interrogate the scrotum. Taxis was employed, 
and the hernia readily reduced. An appropriate trass was ordered , 
and nux vom. given internally. 



V<*«r<*«&» ^f $%® O^ J^tm** I*. 



Geo. R M., Aged Fifty -one Years. 

About twenty months ago there appeared, from constitutional 
causes, at a point one and a half inches above left temple, an 
abscess, which increased until it became the size of an egg. Slough 
came out, and the abscess remained open, suppuration continuing 
this morning a sequestrum about an inch square was discharged, 



184 



SURGICAL RECORDS. 



consisting of the external table of the bone, the underlying diploe 
presenting healthy granulations, with profuse secretion of fetid pus. 
Ordered the parts dressed with Lister's sol. carb. acid, and to be 
taken internally, silicea 200. Care must be exercised to keep the 
hair from the wound in all injuries to parts covered with hair. 



John W., Aged Nine Years. 

Two years ago, without known cause, the left breast began to 
enlarge, with burning, stinging pains, worse at night and in damp 
weather. The breast is soft, and nearly as large as a woman's. 
There is neither hardness nor soreness. 

Phos. 30 was prescribed, it being peculiarly adapted to such 

cases. 

<■♦+»■» . 

Eliza A., Aged Seventeen Years. 

Has pustular eruption on middle finger of right hand, caused 
by wearing a ring. Eruption appeared about two years ago. 
Commences as pustules, which degenerate into a squamous condi- 
tion. Burns after scratching. Eesembles impetigo. 

Sulphur every night and morning. 



Harvey D., Aged Six Years. 

The tumor in scrotum was first noticed about three months ago. 
There is no cough impulse; testicle distinctly felt at bottom of 
scrotum ; translucency distinct when applying a lighted taper ; 
the pains are paroxysmal, so that be screams during motion. 
Exploring needle is followed by exuding of serous fluid. Hydro- 
cele in children may be cured by puncturing, to allow escape of 
fluid and the internal administration of medicine. In adults, how- 
ever, an injection of iodine or a seton is usually necessary. 

Prescribed rhododendron 30, night and morning. The sac was 
punctured and the fluid withdrawn. 



REPORT OF SURGICAL CASES. 185 

Martha P., Aged Thirty Years. 

Been married three years ; has three children. Contracted 
syphilis from her husband. This case is a most remarkable one. 
The nymphae are enormously enlarged, and project beyond the 
external labia, which are also swollen. The clitoris is singularly 
cylindrical in shape, having a length of three inches and a dia- 
meter of one and one half inches. Several pedunculated condy- 
lomatous growths, varying in length from one to three inches, 
appear, arising from the labia minora. The perineum is thickly 
studded with these growths, which extend backward to the anus. 
Complicated with this affection are painful external hemorrhoids. 
Goes for weeks without an evacuation and is in constant distress. 
Prescribed thuya 3, gtt, v. three times a day, topically: 
# Thuya, 3 j. 

Aquae, J vj. 
M. 

Farinaceous diet ordered, also sitz bath night and morning, after 
which the above application is to be made. Must be kept quiet 
and in recumbent position. If these means are not productive of 
good, surgical measures will be resorted to. The use of nitric acid 
and the bichloride of mercury in the treatment of such diseases was 
pointed out. 

Bursa at little finger dissected out, it not having yielded to pre- 
vious treatment. Crepitation at wrist gone. 



Mrs. P., Aged Thirty -four Years. 

About a year ago there came a swelling on left side of face, just 
anterior to and below the ear, accompanied by neuralgic pains, 
which were worse in damp weather. Has earache constantly. 
Has had diseased teeth, which were extracted. It was very sen- 
sitive, especially at one point. Has grown steadily to the present 
time. 

Prescribed Hecla lava 3, three powders daily for a week. 



186 SURGICAL RECORDS. 

There are two forms of exostosis — cancellated and ivory ; the 
former usually attacking the epiphyses of the long bones; the 
latter, by far the most formidable, appears in the flat bones, 
especially those of the head and face. The causes are constitu- 
tional, rarely local. In the case above cited the predisposition 
already existing (the decayed teeth) may have been the exciting 
cause, while the neuralgia may have been the result of pressure 
of the tumor upon the nerves of the part. 



GrEO. Pierce {Sailor), Aged Fifty-one Years. 

{Continued from page 181.) 

For the last week has not been improving. Is alternately 
better and worse. Within the past two weeks several spiculae of 
bone have been discharged from the wound. Were these portions 
larger, the indications would be more favorable. Eecommends 
scraping the bone. To which patient objects. 

Prescribed silicea. 



Chas. J., Aged Twenty-six Years. 

Eight leg injured three months ago by falling plank. Began 
to swell, the swelling going and coming every week, There is 
considerable pain, which is greater in damp weather. Has had a 
fracture of the lower third of the fibula, with partial rotation of 
the astragalus, and rupture of external lateral ligament. The foot 
is somewhat everted. There is some deformity and stiffness of the 
joint. Ordered an elastic stocking for the leg, and prescribed arnica 
externally and internally. The prolonged use of too strong a 
solution of arnica will often produce a condition closely resem- 
bling erysipelas. 



REPORT OF SURGICAL CASES. 



187 



Maey Beaumet, Aged Sixteen Years. 

{Continued from page 180 and to page 83.) 

The operation has been productive of great good. Can now 
masticate her food, which she has not done for nine years. Cica- 
trix remains, which in time it will probably be necessary to dissect 
out. Movement of the jaw must be kept up, and to prevent con- 
traction she must have inserted between her teeth wedges of 
hickory wood. Dec. 6, much improved. 



Mrs. S., Aged Forty -two Years. 

{Continued from page 174.) 

The tumor at middle third of clavicle, which one month ago 
had the appearance of and was diagnosed as enchondroma, has 
now become much more yielding, and is thought to be a sebaceous 
cyst. It was carefulty dissected out, \ T et with some difficulty, as 
it penetrated to within dangerous proximity to subclavian vessels. 
Another method of removal is by suppuration, which can be in- 
duced by means of seton. Wound dressed with carbolic acid. 



gffe<»4}<* im WHit 



Kate M., Aged Tiveniy Years. 

Two weeks since a crochet needle entered radial side of wrist 
and was broken off. An effort had been made to remove it but 
failed. She comes now to the clinic. The needle cannot be felt. 
Was directed to allow it to remain, under the supposition that it 
may make its appearance at the surface, when it could be easily 
removed. The point of exit and point of entrance of such bodies 
are often widely apart. It is useless in this case to make incisions 
around the point of its entrance. 



188 CLINICAL RECORDS. 

Andrew B., Aged Five Years. 

Can protrude the tongue quite well. Can only speak the word 
" mamma." Examination shows fraenum too short. Care must 
be exercised in performing this apparently trivial operation : first, 
lest dangerous hemorrhage occur, and second, lest a too free in- 
cision allow the tongue to fall backward, producing suffocation. 
Cases are recorded where death has resulted from each of these 
causes. 

The operation can be performed with either a curved steel - 
pointed bistoury or with probe-pointed scissors. If a bistoury is 
used, cut from behind and forward. 

Operation performed with a bistoury. 



John C. M., Aged Thirty -seven Years. 

Acquired phymosis. Cannot retract the prepuce at all. Is of 
several years' standing. Has produced spermatorrhoea. Operation 
performed by drawing forward the prepuce, and with the scissors 
cutting it across. The mucous membrane was then trimmed off, 
and the cut surfaces of integument and mucous membrane approx- 
imated by means of silver wire sutures, so that adhesions would 
then unite the mucous with the cutaneous surfaces. Among the 
causes of phymosis are wounds, gonorrhoea, syphilis and balanitis. 

Paraphymosis is a state exactly opposite to the preceding ; is 
often caused by the successful retraction of phymotic prepuce ; or, 
as with phymosis, it may be caused by gonorrhoea or chancroids. 
If this condition is allowed to continue gangrene may result. 
Paraphymosis can often be reduced in the following manner : After 
a thorough application of sweet oil, place the ends of the thumbs 
against the glands, in front, while the index fingers are pressed 
upon the prepuce laterally behind the point of constriction. Then, 
by bringing the fingers forward, while the thumbs exert a counter- 
force upon the glans, the reduction is accomplished. When re- 
duction cannot otherwise be performed, slitting through the point 
of constriction may be resorted to. 



REPORT OF SURGICAL CASES. 189 



Mary M., Aged Eight Years. 

Fistulous opening on right cheek, caused]by scrofula, with enlarge- 
ment of the glands of the neck. Pus exudes ; face pale ; has scrofu- 
lous cachexia. Has pain, which is worse at night. Loses flesh. In 
persons afflicted with scrofula, there is always a tendency to leu- 
cothsemia. Probe discovers no caries. Prescribed calc. 30, twice 
daily. Baryta also is often indicated in this condition. 



<CSito¥!«* 



Martha Pinckney, Aged Thirty Years. 

(Continued from page 185.) 

This was a peculiarly aggravated case of condylomata and 
enlarged clitoris and labia, which were so large as to com- 
pletely cover the vaginal and anal openings and the perin- 
eum; they were from the size of a bean to that of an egg, 
and, if removed, would have filled a two quart measure. 
The patient was born in Virginia, was married to a man from 
whom she had contracted syphilis, to whom she bore three 
children ; she was finally compelled to leave him on account 
of his vices. Strange to say, however, this woman was earning 
her living at service, being obliged to stand upon her feet most of 
the time ; she suffered terrible pain during urination, with, severe 
aching in her bones, chiefly at night. She was also much ex- 
hausted from the bleeding of the tumors. The condylomata and 
the clitoris were pedunculated and covered with unhealthy mucus, 
and, owing to the irritation consequent upon walking, were con- 
stantly bleeding. 

She was ordered (until she could be received into the hospital) 
to have frequent sitz baths, farinaceous food, no meat, compresses 
saturated with one part of tincture of thuja to eight parts of 
water externally, and thuja 3d internally, gtt. iii. three times a 
day. 

Attention was called to the use of the following agents for the 
reflbroid tumors, hemorrhoids, condylomata, and other soft parts, 



190 SURGICAL RECORDS. 

viz: the ecraseur, invented by Chassaignac, nitric acid, mercurius 
corrosivus ( 3 j. to 3 j. collodion) and the galvano -caustic wire, after 
which, the patient being etherized, the enlarged clitoris was re- 
moved by the ecraseur with no subsequent homorrhage ; two small 
candylomata beneath the clitoris were then ligated with a double 
thread and cut off by the scissors. 

These two ligatures and the one through the pedicle of the cli- 
toris were left in, to guard against secondary hemorrhage. The 
patient was then placed in the hospital and the previous treatment 
continued. 

The patient was reported to be doing well. 

The patient, being etherized, was placed in Sims' position, and 
three anal condylomata were ligated with a double thread and cut 
off with the scissors. 

Two large condylomata were ligated and left to slough away ; 
they were all found to be very tough and vascular ; it was then 
ordered that the wounds be dressed at once with cold water, then 
for two days with styptic cotton, which is cotton dipped into a 
solution of tannin, persulphate of iron, benzoic acid and alum. 
Only three condylomata now remained. 

Prof. Helmuth reported that the patient was doing very well, 
and that he had searched the records and found but few similar 
cases, and these were not so severe as this. 



Mary J. M., Agent Eight Years. 

This child was light haired, pale faced, nervous, puffy under the 
eyes, had dilated pupils and presented a general scrofulous appear- 
ance, though the parents and the other children were said to be in 
fair health. 

Eight weeks ago a hard swelling appeared under the right infe- 
rior maxillary, causing the child to cry a great deal, chiefly at 
night, which finally discharged pus externally, since which time she 
has lost flesh. She has had no other glandular swellings, neither 
has she been salivated. There was no disease of the bone, but 
simply a scrofulous enlargement of the parotid gland. Air, exer- 
cise, and calcarb. 30th, a powder three times a day, were ordered. 



REPORT OF SURGICAL CASES. 191 



Anthony W., Aged Fifteen Years. 

This lad suffered from a sprain of his left ankle with severe, 
deep pain, occurring without any known cause, unless due to a 
slight mis-step eight weeks ago ; he had suffered eight weeks since 
with rheumatism. 

A sprain was- described as an accidental rupture or wrenching 
of the parts about the joint, often with dislocation suddenly 
taking place which the muscles at once reduce. The patient had, 
probably, from subacute arthritis, weakened the joint, thus predis- 
posing to the accident. 

There was neither a fracture nor a rupture of the internal 
lateral ligaments. Having been preceded by disease of the joint 
it was ordered that he rest as much as possible, using a crutch 
when it was necessary for him to walk ; he should not touch his 
foot to the ground for six weeks, and must not be exposed to damp- 
ness or be out at night. A cold compress was applied at night, 
covered by flannel and oiled silk, and rhus tox. 3d. gtts. x. in half 
a glass of water, a table spoonful every three hours was ordered. 

He was told that if not properly taken care of, effusion in the 
joint might result and finally fibrous anchylosis. 



Ernest D., aged 7 months. 

This babe presents a peculiar case : its mother states that the 
child snores " terribly " and has great difficulty in breathing during 
sleep and nursing ; when sucking the respirations can be heard all 
over the room. Attention was called to the fact that any obstruc- 
tion in the posterior portion of the mouth, as swelling of the ton- 
sils or a polypus, or an enlargement of the turbinated bones, might 
cause obstruction to breathing. The tonsils or velum palati did 
not seem enlarged, and an attempt was made to pass a small bou- 
gie into the nostrils, which failed ; a small probe was, however, 
with effort passed to ihe posterior nares of either side, and it was 



192 CLINICAL RECORDS. 

found that the turbinated bones were enlarged and the schneide- 
rian membrane thickened, thus closing the passages. The mother 
was instructed to use a syringe with a fine nozzle to throw warm 
water through the nares, and have the probing repeated every 
week or two, gradually increasing the size of the instrument, 
and Hecla-lava was ordered to be administered at night. 



@e^f la* #f %%® 9to?v* am& Tendon 
<^£ *fe# T*msn£s 



Mary B., Aged Nineteen Years. 

Three years ago a playmate pushed a barbed crochet needle 
from over the extensor tendon of the right thumb through to the 
inner and fleshy side of the thumb. Her physician broke off the 
protruding barb and drew the needle back through the point of 
entrance. Since then she has suffered with pain in the thumb 
during bad weather, and with frequently recurring numbness. It 
was pronounced that the nerve and tendon of the thumb had 
been divided, and a simple electrical apparatus was ordered to be 
used once or twice a day as follows : apply a ring of zinc around 
the thumb and one of copper around the wrist, connect these 
with a copper wire and put a little vinegar under the copper ring. 
This is also an excellent appliance in bed sores and obstinate 
ulcers. 



C. M., Aged Twenty-two Years, 

An operation for varicocele being about to take place, the fol- 
lowing very opportune explanation of varicocele and its oper- 
ations was given : 

The tunica vaginalis is a peritoneal investment of the spermatic 
cord and testicle : the spermatic cord is made up of the spermatic 
artery and veins, and vas deferens, the latter carrying the semen 
to the vesiculce seminales ; the pampiniform plexus is the collection 
of veins which pass through the spermatic cord. 

Yaricocele usually occurs on the left side, because the right 



REPORT OF SURGICAL CASES. 193 

spermatic vein enters the vena cava acendens at an aGute angle, 
while the left spermatic vein enters the efferent vein of the kidney 
at a right, angle, and also the valves of the right vein do not open 
as readily as those of the left. 

The symptoms of varicocele are, & feeling of weight in the 
testes, pain in the small of the back, and a depressed mental con- 
dition ; the patients usually are strong, robust young men, of good 
habits, accustomed to hard work and long continued standing. 

The treatment is palliative and radical. The first is by means 
of a suspensory bandage. The second aims to obliterate the en- 
larged veins by either of the following methods, viz : 

1st. Pass a needle armed with a cord behind the vein, making 
the point of exit of the needle near the point of entrance ; then 
twist the ends of the cord and you thus compress the veins. 
Thirteen of fourteen cases treated in this way were cured ; the 
fourteenth died of phlebitis. 

2d. Eemove a crescentic piece of the scrotum, then sew up the 
wound and thus cause compression. 
. 3d. Make an incision through the scrotum and ligate the veins. 

4th. Inject perchloride of iron. 

5th. Put a truss and pad over the external abdominal ring 
through which the veins pass up, and by this means irritate the 
veins and effect a cure. 

That method is the best which excludes the air from the veins. 
It must, also, be borne in mind that ligating the spermatic artery 
will result in atrophy of the testis, and this accident has occurred 
to distinguished surgeons, one of whom was murdered for having 
made a mistake and included the spermatic arteries in his ligature. 
It is better, then, remembering that the vas deferens feels like 
a ligamentous cord ; that the artery can be known by its gentle 
pulsation, and the veins by their feeling like a bundle of earth 
worms, 

6th. To get the vas deferens between the thumb of the left hand 
and the os pubis; the artery between the first and second fingers, 
thus leaving the veins clear for ligation as follows : pass a curved 
needle armed with a double thread with the loop near the eye of 
the needle, in front of the thumb through the integument behind 
the veins; cause it to reappear in front of the first finger and re- 
move the needle ; then enter the unthreaded needle at the same 
point of entrance as before, carry it just beneath the scrotal wall 

13 



194 CLINICAL RECORDS. 

and cause it to emerge at the same point of exit as before ; then 
slip the loop over the point of the needle and tie the loose ends of 
the cord over the other end of the needle ; if you have been suc- 
cessful, the veins alone are included between the cord behind and 
the needle in front and you can compress lightly for four days and 
then more tightly for about ten days longer ; if you have, unfor- 
tunately, included with the veins the artery or the vas deferens, 
and discover it within these four days, no harm is done, for the 
removal of the needle restores everything to its original position. 
As minor points, have your patients wear no suspensory bandage 
for a few hours previous to the operation, and also take exercise 
before the operation to fill the veins ; also, have corks placed on 
the ends of the needles to prevent injury to the scrotum. After 
these remarks the patient was etherized and the last described 
operation was successfully performed. 



Geo. H., Aged Forty -three Years. 

This man presented a very interesting case ; his tongue became 
sore on the right side a year ago, and a white vesicle was noticed 
which he tried to pick off with a knife ; he then took a caustic and 
burned it off two or three times, making it worse. A physician 
gave him tannin to apply which much aggravated the disease, 
though he was assured it would cure him promptly. Since then he 
had used iodide of potash internally. Five weeks ago ulceration 
began with stinging pains through the tongue, chiefly at night and 
in swallowing. Since this time he had used arsenicum, which 
relieved the pains in ten minutes after it was taken. The ulcer- 
ated surface is now about an inch and a quarter long, and one half 
inch deep and has bled once only. It was found that he had 
always been in health, excepting while suffering from a chancre, 
nineteen years ago. He had chewed and smoked tobacco, using 
pipes with amber mouth pieces and also the common clay pipe, 
the latter causing often a stinging pain ; he has ceased, however, 
the use of both coffee and tobacco. 

The disease was diagnosed as an epithelioma, and since arseni. 
cum 30 seemed so well adapted, he was ordered to continue it, a 



REPORT OF SURGICAL CASES. 195 

powder three times a day, unless it became worse, requiring 
removal by the ecraseur or galvano caustic wire. Bread and 
milk, mush, rice and hominy, and mutton broth were ordered, and 
to wash the ulcer with warm water. This patient returned to the 
hospital to have the entire tongue removed, but before the ap- 
pointed time, left without assigning any reason. 



# 



Randolph R., Aged Eleven Years. 

This child had a swelling which appeared suddenly in his scro- 
tum five months ago, and no effort had been made by his parents 
to have it attended to, though it had sometimes become " almost 
black." It gave cough impulse, hence was not encysted hydro- 
cele of the cord ; it was not infantile, because the testicle was at 
the bottom and was pronounced a congenital oblique inguinal 
hernia still reducible. The gut was returned without difficulty, 
and it was ordered that the child wear a truss and have nux 
vom. 30th , a powder every night, to strengthen the muscles of the 
abdominal wall. 



ParHat 3Pa*aty»i»* 



J. BURNS, Aged Four Years. . 

This man reports that he began to suffer with stinging pains in 
his hips during walking three years ago ; in the course of a year 
his right leg became a little lame, and is now smaller and shorter 
than the other ; his leg "goes to sleep " and becomes cold very 
easily ; he is unable to raise his foot, and suffers with severe pains 
shooting down the anterior surface of the leg. His symptoms are 
ail worse in damp weather, and his appetite very poor. His 
physician had called it sciatica, cupped him, and gave him medi- 
cine with no benefit; he has also used rhus to& for ten days with- 
out effect. He had never had a blow upon his back or a strain, 
nor suffered with pain in the knee. 



196 CLINICAL RECORDS. 

It was pronounced a threatened paralysis, and electricity to be 
the best treatment, but, since we are unable to furnish him with 
this for the present, he was given colocynth to be taken every 
fifteen minutes during his severe pains, and ordered to moisten a 
flannel rag in alcohol, having a tablesponful of salt to the pint, 
and to rub his leg with this night and morning, also to take plenty 
of out door exercise. 

The internal medicines were rhus tox. at first, and afterward 
strychnine. 



&&%%$&* S^aeta?** 



David G\, Aged Seventeen Years. 

This young man had fallen through a hatchway ten weeks ago, 
and sustained a Colles 7 fracture, viz., a fracture of the lower ex- 
tremity of the radius, with dislocation of the ulna, which had 
been treated with a pistol splint, and he probably came to see if 
it had been properly managed. He was told that it was not neces- 
sary to break the bone over again, and that time, friction and 
exercise would help him regain the normal motion of the joint. 



J. L. S., Aged Thirty-eight Years. 

The following diagnosis of hydrocele and description of the 
methods of cure were made before the operation. Hydrocele of 
the tunica vaginalis is a collection of serous fluid between the 
tunica vaginalis testis and the tunica communis. 

This man's trouble began seven years ago, and is a hydrocele, 
because the swelling began at the bottom ; it gives no cough 
impulse, he has severe pains in the back and groin, is very de- 
pressed, mentally ; the tumor is translucent and irreducible ; while 
hernia comes from above, has cough impulse, can usually be 
reduced by taxis, atid is opaque. 

Varicocele, on the other hand, has the peculiar earth worm feel- 
ing of the veins. 



REPORT OF SURGICAL CASES. 197 

Some cases of hydrocele can be cured in youth by medicine, and 
encysted hydrocele of the cord in infants will often spontaneously 
disappear. The methods of cure mentioned were by, 1st. Seion : 
Insert a trocar and draw off the fluid ; then push the trocar up- 
ward through the scrotum, withdraw the trocar, leaving in the 
oanula, through which pass a cord ; then having withdrawn the 
canuhi, tie the loose ends of the cord. 2d. Injection. Iodine can be 
injected into the tunica vaginalis, causing sufficient inflammation 
to cure ; or still better is the injection : 
5, Iodide of Potash, 3 ij. 
Water, J ss « 
Tincture of Iodine, 3 iv. 
M. 

3d. Incision. An incision can be made through the scrotum, 
and the fluid drawn off; this sometimes is sufficient. 

4th. Electrolysis. 5th. The Aspirator. This instrument consists 
of a graduated glass jar having two rubber tubes of three feet 
each. At the extremity of each of these tubes is attached a brass 
piece furnishing a thread on the end and a stopcock ; each aspira- 
tor is furnished with a set of capillary needles, that screw on to 
one of the brass pieces mentioned, and has also a small brass air 
pump which is attached to the other brass piece. 

Operation. Attaching a needle to one rubber tube, the air pump 
to the other, close the stopcock next to the needle and open the 
one next to the air pump ; work the piston of the pump, which 
exhausts the air from the jar and tubes, then, having inserted the 
needle in any fluid tumor (in this case the scrotum), the contents 
of the tumor are forced into the previously formed vacuum of the 
jar : the puncture of the needle being capillary, no air can enter 
the exhausted cavity, and the operation can be repeated without 
injury. In this case the last mentioned injection was used (after 
the evacuation of the sixteen ounces of yellow and thick fluid of 
the hydrocele) by an improvement of Prof. Helmuth's on the as- 
pirator. To the needle used, had been added a stopcock at 
its posterior extremity ; after the withdrawal of the fluid from 
the scrotum, this stopcock was closed and the aspirator tube un- 
screwed from the needle and taken away ; a J^rass syringe charged 
with the injection was then screwed to the needle, the stopcock 
on the needle opened, the injection forced in and allowed to re- 
main two minutes ; the injection was then drawn back into the 



198 CLINICAL RECORDS. 

syringe, and the needle was withdrawn from the scrotum, and 
thus the whole operation, consisting of the removal of the con- 
tents of the tumor, the injection into the cavity, and the removal 
of the injection, was accomplished by one capillary puncture. 



JOHN D., Aged Four Years. 

This fcov had teen troubled with a vesical calculus, which had 
become lodged in the prostatic portion of the urethra, causing 
great difficulty in urination, and at times suppression ; there was 
danger of rupture of the urethra and extravasation of urine; his 
prepuce was elongated, symptomatic of calculus, and he had also 
the frequent inclination to urinate which belongs to the disease. 

As to the operation: If possible the stone was to be removed 
through, the urethra by a fine pair of urethra forceps. The pa- 
tient was etherized and the extracton attempted, but it was unsuc- 
cessful ; recourse was then had to the removal through the peri- 
neum, which was successfully done .by the lateral operation, and a 
stone the size of a bean removed ; the incision was made high up 
in the perineum on account of the position of the calculus ; some 
little difficulty was experienced in securing a small deep artery, 
cut during the operation. 

After the operation the boy was removed from the hospital. 

Jan. 17th. Prof. Helmuth reported that on the 12th inst. the 
boy had been removed without his knowledge to his home in New 
Jersey, and that, as soon as he discovered it, he had written to a 
physician there to see him daily and report. He had done so, and 
all went well till the 16th inst., when it was found there was in- 
filtration of urine into the tissues of the scrotum, which were 
purplish in color. 

The Professor had him returned to the hospital, and he finds 
that he passes about one half of his urine this morning through 
the urethra. It was ordered that the scrotum be strapped up by 
adhesive plaster attached to the abdomen, and he be carefully 
watched. The Professor stated that it was possible for one to re- 
cover after losing one half the scrotum from this cause. No ca- 
theter was to be used in this case. 



REPORT OF SURGICAL CASES. 199 

Jan. 24th. After the scrotum had been strapped up a very 
small am >unt of urine escaped through the perineal wound for 
three days, since which none had escaped, and the purplish spot 
was nearly gone. 

Attention was called to the fact that there is more danger of in- 
filtration of urine when the triangular ligament is divided, as in 
this operation, than in other operations for the urethral calculus. 

Jan. 3 1st. At this time all the urine was passed through the 
urethra, the purplish, appearance of the scrotum was all gone, and 
the boy prenounced cured. 



Cured by Digital Compression in 72 Hours. 



Chas. D. (colored), Aged Fifty Years. 

Before this man was brought into the theatre, attention was 
called to the following particulars : 

An aneurism is a tumor containing blood and communicating 
with the cavity of an artery. The ordinary or encysted aneurism 
is sub-divided into several classes, thus ; it is called fusiform, 
when the whole circumference of the artery was expanded ; 
pedunculated, when there is a small opening between the 
aneurism and the artery ; true, when all the coats of the artery 
are expanded ; false, where the internal and middle coats are up- 
turned ; diffuse, when the sac walls are formed by cellular tissue ; 
dissecting, when the blood passes between the coats of the artery. 
Any sudden and rapid strain of a joint may give rise to an aneur- 
ism ; a clot forms on the wall of the sac, becoming almost organ- 
ized, which thickens the coat of the artery and is called after Brocca, 
the active clot; this sometimes proceeds to such an extent as to 
cure the aneurism and is Nature's method of cure. The " passive 
clot" is a currant jelly-like substance found in the centre of the 
aneurism. The method of cure of Antyllus, which is the oldest, 
is to ligate the artery above and btdow the aneurism, cut down on 
the sac and empty it of its contents. AneVs method was to ligate 
the artery on the cardiac side near the aneurism. Hunter s method 
was to ligate the artery on the cardiac side at some distance from 
the aneurism. Wardrop and Brasdors 1 method was to ligate the 



200 CLINICAL RECORDS. 

artery on the distal side of the aneurism. Other methods are by 
tourniquet to arrest the flow of blood from behind and thus allow 
a fibrinous clot to form and obliterate the sac. Both a single and 
double ball tourniquet have been used, but the latter is the better, 
as it allows a change of pressure from one spot to another and thus 
relieves the patient. The manipulation method is devised to com- 
pel the u active clot" to change its position, to enlarge, fill up and 
obliterate the sac. Sometimes ulceration and sloughing occurs 
spontaneously in the aneurismal tumor. Forced flexion ; acupres- 
sure, used by Sir James Simpson, and digital compression are all 
employed by surgeons at the present day, but the latter method, 
when there are intelligent assistants at hand, is the best This 
compression may be continued from four to seventy-five hours, 
as may be necessary ; one case at least is on record where the pa- 
tient effected a cure by compression with his own hands in four or 
five hours. 

Strange to say popliteal aneurism often occurs in negroes, and 
the symptoms are, after undue exertion of the leg, a sudden pain, 
snap and faintness, and a pulsating tumor is found in the popliteal 
space; sometimes a fibrinous clot forms on the walls of the sac, 
making the pulsation less distinct and even finally imperceptible. 
If the ear is applied over the aneurism, a blowing or rasping 
sound is heard, called the bruit; the pressure on the surrounding 
veins causes them to become varicose. This man was in the habit 
of carrying a heavy sick woman from her carriage to her room ; 
on one occasion he felt a snap and a severe pain down his left leg, 
and found the next day a tumor behind his knee and the veins of 
the leg swollen and the leg stiff. 

Pulsation could not now be felt very distinctly, on account of the 
active clot. 

Thirty of the class having volunteered to make digital compres- 
sion as long as necessary for the cure of this case, they were 
divided into six classes of five each, each class to remain on duty 
three hours and each member to compress twelve minutes of each 
hour. Pressure was begun at 6 P. M. ; patient's temperature in 
the axilla at this time way 98-£°, the temperature of the tumor 
was 96, and his pulse was beating 80 per minute. 8 P. M. pulse 
came up to 88, at 9 P. M. going back to 80 ; the pain at this time 
became unbearable, requiring the use of morphine. At 11.40 
p. M. he was seized with severe rigors lasting but a short time, his 



REPORT OF SURGICAL CASES. 201 

temperature running down to 94£° and his pulse to 81, remaining 
till morning between 71 and 76. 

Jaic. 11th. At 8 A. M. his pulse came up to 84, and his tem- 
perature to 98£° ; by noon the pulse reached 94. Only slight pul- 
sation could now be detected in the tumor. At 3 P. M. the pulse 
was 104, decreasing gradually, reaching 88. At 5.40 P. M. the 
patient was quiet and suffering no pain. At 6 P. M. pressure was 
taken off for a moment, the pulsation found to be very slight and 
a movable clot plainly discernible. Between 9 P. M. and morning 
the patient slept a little during each pressure, waking at every 
change; at 10.30 P. M. there was some subsaltus tendinum. 

Jan. 12th. At 1 a. m. the patient's temperature was 98J°, pulse 
100 which decreased to 92 by 6 A. M. At 3.15 A. M. there was 
further subsultus tendinum ; at 9 A. M. his pulse was 94, his tem- 
perature 99J° and that of the tumor 94J°, and he was suffering 
no pain. At 3 P. M. his pulse was 105: at 4 P. M. it was 98 and 
temperature of the tumor 96|°. At 6 P. M. his temperature was 
99f ° and that of the tumor 98£. 

-Jan. 13th. At 4 a. m. his pulse was 91, gradually reducing to 
84 by 6 A. M., when his temperature was 99° and that of the 
tumor 98f°. At 3 P. M. his pulse was 92, his temperature 99 \° 
and that of the tumor 96£°. At 9 A. M. his pulse was 82, his 
temperature 98^° and that of the aneurism 98^°, at which time, 
after 75 hours' pressure, it was discontinued. Prof. Helmuth had 
taken great interest in the case, visiting the patient daily at 9 
A. M.. noon and midnight, and leaving nothing undone that could 
contribute to success. Great credit was due the class for their 
kindness and attention. The patient slept well all night and 
woke in good condition, though exhausted. 

Jan. 14th. The tumor was carefully examined by Prof. Hel- 
muth, Thompson and Eobinson, Drs. Baldwin and McYicar, and 
others, and no pulsation could be detected, and the tumor was 
found to be gradually reducing and hardening ; the collateral cir- 
culation had been growing better day by day, and was now very 
well established, pulsation being distinct in the articular arteries. 
An examination was made daily and no pulsation detected. 

Jan. 17th. Prof. Helmuth reported in the clinic that he 
regarded the patient as cured ; but, for fear there was a small 
stream passing through the sac, ordered pressure to be resumed 
on the 18th at 9 A. M. and kept up for 12 hours, to be again re- 



202 CLINICAL RECORDS. 

sumed on the 19th at 9 A. M., and kept up for twelve hours, which 
was done. Up to the 24th inst. no pulsation could be detected, 
the tumor was two thirds gone, and the patient was brought into 
the amphitheatre and questioned. In reply, he stated that he had 
been walking around for two days and felt no pain in the knee, 
whereas before the operation for weeks he had suffered most ter- 
rible agony, had been unable to lie down at all, or put his foot 
on the ground, and had used opium and every thing he could get, 
to relieve his pain, without any relief. 

He was instructed to go home on the 26th and to keep up pres- 
sure every morning and night for fifteen minutes, and to return 
in three weeks ; and was pronounced cured. On the 26th Prof. 
Helmuth came to the hospital with his carriage to take the 
patient home, for fear he might injure himself if he went home 
on the crowded street cars, and found the patient had climbed 
over the transom of the door of his room, and, taking a crowded 
car, had fled. 

Feb. 2d. Prof. Helmuth reported that the patient was able to 
put his heel within a half inch of the ground, was able to work, 
and was earning his living. 

W. H. Post, Aged Forty-one Years. 
This gentleman was sent here by his physician to satisfy him- 
self that his diagnosis was correct. A year and a half ago he 
had typhoid fever : a year ago his right breast became hard and 
sore, and then discharged freely both blood and pus for three 
months, but during the last nine months pus alone ; neither air 
nor bits of bone had ever been discharged at any time ; he had 
been in good health for months and was getting flestry. The 
probe entered the opening beneath the nipple an inch and a 
quarter. It was pronounced Empyema, and silicea was ordered. 



Mary H., Aged Sixteen Years. 
Adventitious bursa of ulnar side of left wrist. Contains trans- 
parent fluid. Passed a seton. 



REPORT OF SURGICAL CASES. 203 



Matilda B., Aged Eleven Years. 

Attention was first called to the following operation for naevi : 
1st. Electrolysis, which is not always successful. 2d. By placing 
two pins at right angles beneath the naevus and li gating it with 
thread beneath the pins, being careful to insert and withdraw the 
pins in sound tissue, which causes less hemorrhage aud insures 
better succes?. 3d. By Perchloride of Iron. 4th. By Nitric Acid. 
5th. By Pressure. 6th. By Vaccination. 7th. By a thread soaked 
in Nitric Acid and drawn through. 8th. By passing two cords 
beneath the naevus in one direction, two others beneath it at right 
angles to the former two, then tying and constricting the naevus 
in quarters and allowing it to slough away. This being a typical 
case, operated on once before by electrolysis unsuccessfully, the 
last mentioned method was employed after etherization. Atten- 
tion was called to the use of nitric acid to cauterize any twigs 
that may reappear: if done at once it avoids another operation ; 
also to the fact that some naevi are so large as to occupy one side 
of the face and require the ligation of the common carotid ; also 
to the primary and transient anaesthesia caused by ether very 
soon after its administration, during which minor and brief opera- 
tions can often be performed, and the secondary and more pro- 
found anaesthesia following. 

Jan. 24th. Patient was brought in doing nicely ; the mother 
was instructed to dress it with simple cerate and return to the Dis- 
pensary in three days. 



Isaac R, Aged Fifty -one Years. 
This was a case that has given rise to some discussion among 
surgeons, and the man has been before all prominent American 
surgeons and in many College Clinics. He carried certificates 
from many surgeons, most of whom pronounced it an aneurism of the 
thoracie and abdominal costa, and with these certificates he was 
able to secure a living. His history and symptoms were as fol- 
lows : two and a half years ago he was working at his trade, 
steel pen making, when he noticed a swelling in his back which 



204 CLINICAL RECORDS. 

annoyed him in lying down, causing a choking feeling and increas- 
ing till he had fainting spells ; his abdomen then began to swell, 
chiefly on the left side, and he began to pass blood with his stooL 
He now passes about three table spoonfuls with every stool, can- 
not lie down at all, and is about the size of a woman with child 
at term. 

Attention was again called, to the subject of aneurism — to the 
false variety, where the external coat only of the artery is ex- 
panded, the internal and middle being ruptured, to the true variety 
where all the coats are expanded, to the dissecting, where the blood 
passes between the laminae of the middle coat usually, after pass- 
ing down the course of the artery, rupturing the internal coat and 
connecting again with the circulation. Prof. Helmuth expressed 
the belief that this was a dissecting aneurism ; one peculiarity of 
the case was that no pulsation could be felt. The man is liable to 
death at any moment, but may yet outlive his physicians. 



C. W. S., Aged Three Months, 

The mother of this baby, who seemed perfectly posted as to the 
case, stated that when the child was three weeks old she first 
noticed that it had a hydrocele on the right side, and that a 
rupture descended every four or five days, swelling the scrotum 
like an egg and causing the child much pain ; she was about to 
have a truss fitted to the child, thinking that it would cure both 
affections. Examination showed translucency and that it was not 
a hydrocele of the tunica vaginalis, because the scrotum could be 
drawn down readily and was not evenly distended, but was an 
encysted hydrocele of the cord accompanied by oblique inguinal 
hernia. An exploring needle was very carefully used and the 
fluid drawn off, which will probably excite sufficient inflammation 
to produce a cure; and she was instructed to have a truss fitted 
after two or three days. 



INDEX 



A. 

Abscess 128, 132 

Treatment of 128, 132 

Aneurism.— Difference in diagnosis 
between an Abscess and Aneurism. 119 

Acute Necrosis 171 

Treatment of 171 

Amputation of the Arm 164 

Breast 172 

Finger 182 

Anaesthesia 16, 99 

Local 137 

Anaesthetic Ether 16 

Anchylosis of Knee Joint 174 

Treatment of 174 

Lower Jaw 83, 126, 180, 187 

Operation for 84, 180, 187 

Treatment of... 84, 126, 180, 187 

Eight Shoulder 174 

Treatment of 174 

Aneurism 77, 203 

Aorta, of the 153 

Treatment of 155 

Quizzes on 110, 118 

Popliteal, of the 149 

Treatment by Digital 

Compression 200 

Subclavian, of the 39, 48 

Treatment of 49 

Ligature in 50 

Angular Curvature of the Spine 24, 41, 93, 

s 94, 117 

Treatment of.. 25, 42, 93, 

95, 117 

Anus, Fissure of 173 

Operation for 173 

Aorta, Aneurism of 153 

Treatment of 153 



Bursae 73, 175, 178, 181, 202 

Treatment of 73, 175, 178, 181, 202 

Breast, Amputation of 172 

c. 

Cancer of the Lip 19 

Operation for 23 

Treatment of 23, 89 

Mamma 171 

Operation for 172 

Treatment of 172 

Caries of Femur 180 

Treatment of 180 

Cartilages, movable 140 

Operation for 141 

Cartilaginous Tumor 174, 187 

Cartilages, Ulceration of the Articular 178 

Treatment of 178 

Cauda Equina, injury to the 149 

Treatment of 152 

Chloroform 16 

Administration of 99 

Cheiloplasty 83 

Cicatrices 25, 72 

Treatment of 26 

Cleft Palate 55, 133 

Operation for 59, 133 



Cold Abscess 87, 113, 120 

Treatment of 87, 114 

Colles Fracture 196 

Concluding Remarks 166 

Condylomata? and Enlarged Clitoris. . . 185, 189 
Treatment of, 185, 189 

Congenital Hernia 76 

Congestion— Quizzes on 28 

Cynanche Tonsillaris 33 

Treatment of 84 

Cystic, Sebaceous Tumor 187 

Treatment of 187 

Cystic Tumor 179 

I>. 

Dementia 114 

Dislocations.— Difference in the diagnosis 

between Fracture and Dislocation 100 
Dislocation of the Femur on the Dorsum 

Ilii 93 

Dog Bite 63 

Treatment of 63 

E. 

Earth Treatment of Ulcer 164 

Empyema 172, 202 

Treatment of 173, 202 

Encephaloid Tumor of Left Mamma 172 

Operation for 172 

Treatment of 172 

Enchondroma 174 

Encysted Tumor 126 

Hydrocele 184 

Treatment of 184 

Epithelioma of the Lip 19, 32 

Treatment of . . . 23, 39 

Operations for 23 

of Mamma 171 

Treatment of 171 

Tongue 194 

Treatment of 194 

Epulis 54 

Operations for 54 

Erosion of Laner Canthus 177 

Treatment of . . 177 

Eruption, Pustular 184 

Treatment of 184 

Ether 1« 

Administration of 98 

Exostosis of Great Toe 177 

Treatment of 177 



Felon 64, 130, 157, 159 

Treatment of 64, 131, 167, 159 

Femur, Caries of 180 

Treatment of 180 

Fistula in Cheek 189 

Treatment of 189 

inAno 173, 177 

Operations for 176, 177 

Frsenuin Lingua?, Malformation of the — 188 
Operation for 188 
Fractures.— Difference in the diagnosis be- 
tween Fracture and Disloca- 
tions 100 

Mode of Repair in 160 

Union in Compound Fracture. 161 



206 



INDEX. 



PAGE. 

Fracture of the Humerus 9, 31 

Inferior Maxilla 148 

Paterson Case 12 

Potts 186 

Treatment of 186 

Quizzes on 7, 8, 9 

of the Lower Extremity of the Ka- 

dius 9P> 

of the lower third of the Ulna.. 152, 159 



G. 



Ganglion 175 

Treatment of . 175 

Gangrene Traumatic 164 

H. , 

Hemorrhage, internal '. 173 

Hsemostatices— Quizzes on 110 

Hemorrhoids removed by Platina wire 173 

Hernia, Congenital 76, 106, 157 

Treatment of 158 

Double Scrotal 183 

Treatment of 183 

and Hydrocele 204 

Operation for 204 

Quizzes on 109, 110, 111 

Oblique Inguinal 195 

Treatment of 195 

Hip Joint Disease, 60, 79, 85, 86, 104, 105, 115 

116, 142, 165 

Treatment of .61, 85, 86, 105 

117, 165 

Housemaid's Knee 73, 178 

Treatment of 73, 178 

Hydrocele 128, 196 

Treatment 128 

Operation for 197 

Hypertrophy of Clitoris 185, 189 

Treatment of... 185, 189 

Mamma 179 

Treatment of 179 

in Boy 184 

Treatment of 184 

Tonsils 33 

Treatment of 34 

Nose 129 

Treatment of 130 

Parotid Gland 190 

Treatment of 190 

Hypochondriasis 89 

Treatment of 89 

Hypospadias 179, 181 

and retained testicle 112 

I. 

Impediment in Speech 173 

Inflamed Ulcer 162 

Treatment of 163 

Indolent Ulcer 85 

Treatment of 37 

Inflammation— Quizzes on 28 

Injury to the Cauda Equina 149 

Treatment of.. 152 

Innonimata, Ligature of 49 

Inferior Maxilla 185 

Treatment of 185 



Jaws, Lower, Anchylosis of... 83, 126, 180, 187 
Operations for 84, 180, 187 

Joints, Anchylosis of Elbow 126 

Treatment 126 

Loose Cartilage in 140 

Operation for 141 



K. 

Knee, Housemaid's 73, 178 

Treatment of 73 

Knee Joint, Disease of 178 

Treatment of 178 

L. 

Lateral Spinal Curvature 44 

Treatment of 46 

Ligament Rupture of the Coraco, Claviclar 
Ligament, and Bruised Capsular Liga- 
ment 138 

Ligation of the Innominata 49 

Subclavian 50 

Lithotomy 198 

Lip, Epithelioma of 19, 32 

Operation for 23 

Lipoma Nasi 129 

Lockjaw— Quizzes on 110 

Loose Cartilages in Joint 140 

Operation for 141 

Lower Jaw, Fracture of 148 

31. 

Mamma, Cancer of 30, 171 

Mammary Gland, Preternatural Enlarge- 
ment of 179 

Treatment of 179 

Hypertrophy 184 

Treatment of 184 

Mother's Mark 38 

Movable Cartilage 140 

Operationfor 141 

N. 

Nasal Passages— Obstruction of 191 

Treatment of 192 

Nevus 13, 19, 106, 203 

Treatment of 14, 15 

Operationfor 15, 18, 203 

Capillary 176 

Necrosis, Acute 171 

Treatment of 171 

of the OsFrontis 183 

Treatment of 181 

Jaw 181, 186 

Treatment of 181, 186 

Tibia 65 

Operationfor 70 

Frontal Bone 31 

Treatment of 82 

Needle, broken 104 

In wrist , . 187 

Neuralgia of the Stump 101 

Treatment of 103 

Node 176 

Treatment of 176 

Nose, Hypertrophy of 129 

o. 

Oblique Inguinal Hernia 195 

Treatment of 195 

Obstruction of Nasal Passages 191 

Treatment of 192 

Onychia Maligna 136 

Operation for 137 

Oesophagus, Stricture of 74, 95 

Treatment of 76, 95 

P. 

Paralysis of the Ejaculatory, Ducts 123 

OEsophagus 131, 143 

Treatment of 145 

Traumatic 29 

Treatment of 29 



INDEX. 



207 



Partial Paralysis 195 

Treatment of 195 

Pharaphvmosis 100 

Paronychia 64, 130, 159 

Treatment of 64, 131, 159 

Parotid Gland, Scrofulous Enlargement of. 190 

Treatment of 190 

Paterson Case, Fracture 12 

Periostitis 130 

Treatment of 131 

Periostitis and Caries 176 

Treatment of 176 

Phlebolithes 134 

Phymoses 51, 100, 188 

Operation for 52, 188 

Pleuritic Abscesses 171 

Treatment of 172 

Popliteal Aneurism 199 

Treatment bv Digital C mpression of 200 
Pott's Disease of" the Spine, 24, 41, 93, 94, 117, 

156 

Treatment 42, 93, 95, 117, 156 

Fracture 186 

Treatment of 186 

Preternatural Mobility , 10 

Prolapsus Ani 46 

Treatmentof 47 



410, 



Quizzes— Abscess, Aneurism. . . . 

Aneurism 

Aorta 

Congestion 

Fracture 7, 

Dislocation 

Fracture of Lower Jaw 

Heruia 109, 110, 

Hip Joint Disease 

Inflammation 

Innoniinata Artery 

Inter-columnar Fascia 

Suppuration 29, 

Tetanus 

Ulceration 



R. 



Repair in Fracture — 
Remarks, concluding. 



119 

118 

91 

}, 9 

100 

162 

111 

100 

28 

91 

91 

162 

110 

37 



166 



s. 

Salivary Glands.— Enlargement of Glands.. 124 

Treatment of 125 

Scirrhus 30 

Treatment of 30 

Scrofulous Enlargement of Parotid Gland . . 190 
Treatment of. 190 

Sebaceous Tumor of Scalp 173, 187 

Treatment of 175, 187 

Sebaceous Tumor 97, 108 

Operation for 98 

Section of the Nerve and Tendon of the 

Thumb. 192 
Treatment of. 192 

Specific Ulcer , — 182 

Treatment of 182 

Spermatorrhoea 121 

Treatment of 124 

Spine, Angular Curvature of 24 

Sprain of Ankle 191 

Treatment of 191 



PAGE. 

Spurious Anchylosis of Knee Joint 174 

Treatment of 174 

Right Shoulder.... 174 

Treatmentof 174 

Staphyloraphy 59, 133 

Stricture of the Oesophagus 74, 95 

Treatment of.. 76, 95 

Subacute Thecitis 145 

Treatment of 147 

Subclavian Aneurism 39, 48 

Treatment of 49 

Ligature of 50 

Suppuration— Quizzes on 29, 162 

Synovitis 53, 176 

Treatment of 53, 176 



T. 

Talipes Equino- Varus , 

Operation for 

Tetanus— Quizzes on 

Testicles Retained 

Thecitis, Subacute 

Treatmentof 

Toe Nail— Disease of 136, 

Operation for 

Tongue Tie 

Operation for .' 

Epithelioma of the 

Treatmentof 

Tonsillitis 

Treatmentof 

Tumor Cartilaginous 174, 

Cystic 

Enchondi-omaous 174, 

Treatment of 

Encysted 

Treatment of 

Encysted Hydrocele 

Treatmentof.. 

Quizzes on 117, 

Sebaceous 97, 108. 

Treatment of 

Traumatic Gangrene 

Paralysis 

Treatmentof 



u. 



Ulcer, Indolent 

Treatment of 

How to apply Straps. 

Inflamed 

Treatment of 

Specific 

Treatment of 

Varicose 

Operation for 

Ulceration 

Ulcer 



Varicocele , 

Operation for 

Varicose Ulcer 81, 

Treatment of 82, 

Varicose Veins 

w. 

Whitlow 64, 130, 157, 

Treatmentof 64, 131, 157, 

Wound of Mouth 



172 
172 

110 
1T2 
145 
147 
177 
1ST 
1SS 
188 
194 
194 



1S7 
179 
187 
187 
126 
126 
184 
184 
118 
173 
98 
164 
29 
29 



35 



162 
163 

182 
183 
81 
82 
27 
27 



192 
193 
128 
129 
134 



159 
159 

180 



